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In Whose Hands?

In all probability, by the time this column goes to publication in December, I will be the mother of two boys, a preschooler and a newborn.

At the time of this writing, however, I am still eight months pregnant and seeing my obstetrician in Boston every three days to monitor a condition I have been diagnosed with called "PIH", or pregnancy-induced hypertension. By definition this means my blood pressure has measured at least 140/90 for at least two days in a row during my last trimester. Obstetricians watch women during the second half of pregnancy, and particularly in the last trimester, for signs of hypertension, because when accompanied by excessive swelling and excretion of protein in a woman's urine (proteinuria), hypertension is often a symptom of a more serious condition called pre-eclampsia, or toxemia.

Pre-eclampsia is a serious condition because, if left undiagnosed and untreated, it can prevent the placenta (which provides air and food to the baby) from getting enough blood. If the placenta doesn't get enough blood, the baby receives less air and food. This can result in low birthweight and other problems for the baby. Fortunately, these days, pre-eclampsia is usually detected early in women who get regular prenatal care, and serious problems can be prevented.

So far, for the past three weeks, the treatment prescribed to me has essentially consisted of as much bedrest as I can take (not so simple with a three-year old, but I am managing together with a saintly mother- in-law), having my blood pressure monitored as often as possible, currently twice a week, and going on a fetal monitor at least once a week to ensure that my baby is continuing to thrive in utero (which, so far - thankfully - he is).

As is the case with many medical specialties, the practice of obstetrics has evolved dramatically in recent years. I am now 31 years old. In the span of my own lifetime, safe abortions have been declared legal in the United States and the world's first "test-tube" baby has been born to the type of fanfare that greeted surviving quintuplets in the 1930s, when my own parents were born. When I was in grade school, surviving sextuplets made the newspapers and both ultrasound and amniocentesis were considered "new" and "experimental" diagnostic methods to monitor the development of the fetus in utero or to detect potentially hazardous genetic defects.

Now that I am an adult, there are the thriving McCaughey septuplets, and IVF, or in vitro fertilization,though still an expensive procedure, is one of the most common solutions to infertility that would have been irremediable twenty years ago. Cloning is now the latest biomedical news, and having already witnessed so many advances myself, I would be naive to assume that in twenty years, cloning might not be as common as IVF has become today. It is the rare pregnant woman with prenatal care nowadays who does not undergo at least one ultrasound examination in the course of her pregnancy. ( In fact, I myself had five ultrasounds in my first pregnancy, and have had three so far with my second.)

Sometimes it is hard to believe how fast things are changing. Even since my last pregnancy, which was only three years ago, much has evolved. Last week at the doctor's office, for example, I underwent a Streptococcus Group B culture that is now considered routine for many women towards the end of the third trimester. "Strep Group B" is a strain of bacteria which, when found in the vaginal tract of a pregnant woman can cause a variety of serious problems if passed on to a newborn at delivery. In certain cases, it can do irreparable harm, sometimes causing fatal damage to the brain and other organs. It is treated by the infusion of IV antibiotics immediately prior to delivery - but effective treatment and the timing of the antibiotic treatment must of course depend on knowing the infection is present.

Although the test existed during my first pregnancy, in 1995, my care provider didn't include a Strep B culture as part of the standard package of prenatal tests for an otherwise healthy pregnancy. This time around, however, I find that it is. What new tests await me by the time I have my third child, I wonder?

Sometimes, I imagine a woman can get so caught up in today's virtual maternity "conveyor belt" that it can become hard to imagine how healthy children were ever born without the benefits of modern medicine.

It is true, of course, that by today's standards, maternal and fetal death rates were quite high. As the noted historian Laurel Thatcher Ulrich points out in her Pulitzer Prize-winning annotated biography of Martha Ballard, a colonial midwife who kept a diary of her practice from 1785 to 1812, the mortality rates were sometimes extraordinarily high in some eighteenth century London and Dublin hospitals, where maternal deaths could range anywhere from 30 to 200 per 1,000 births. Conversely, as Ulrich notes, Martha Ballard's own records kept during the 27 years of her midwifery practice, indicate only 5 maternal deaths per 1,000 deliveries. While today the maternal death rate stands at less than 1 per 10,000 deliveries, as late as 1930 there was one maternal death for every 150 births in the United States.

Ulrich continues to note that the the major advances in obstetrical safety have come only in the last half-century. There is evidence that during the nineteenth century in Western civilization in particular, the increasingly fashionable and routine employment of physicians (rather than midwives) probably increased rather than decreased mortality rates. Historians believe this was partially due to the increasingly complex approach physicians took towards childbirth - employing opiates and instruments such as forceps, which purported to aid laboring mothers, but in reality often harmed them and their infants instead.

In an age where the mechanisms of viral and bacterial infection were barely understood, it is certainly not hard to understand how maternal and fetal death rates soared when women were delivered by unsterilized hands and instruments in crowded, unsanitary hospital wards and why some women were, in fact, arguably better off in those times delivering alone in the "backwoods."

As any modern obstetrical textbook will confirm, despite the "miracles" of modern medicine, 99% of any healthy, uncomplicated pregnancy today still progresses without any medical intervention whatsoever. The overwhelming majority of my own obstetrical appointments in the past 6 months, for example, have had no other medical purpose than to serve as "tummy checks," where my physician or her assistant does little more than record my weight, take a urine sample, check my blood pressure, and listen to hear that my baby's heartbeat continues to be steady and strong. As I was reassured during my first (thankfully uncomplicated) labor, my own body was doing most of the work, not my physician.

"Have confidence in your own body", the doctor who delivered my first son advised me. "Nine times out of ten, it knows what it's doing." Even the formula companies acknowledge in all their advertisements that breastfeeding is still the optimum form of nutrition for infants. One feels obliged to note that the same modern medicine that brought women safe caesarian sections and which today can save the lives of infants born up to four months premature, also not so long ago, introduced the previously unknown, devastating effects of the once so-called "miracle" drugs thalidomide and DES.

Even the most ardent naturalist midwives recommend home births only for those women whose pregnancies have been healthy and whose deliveries are presumed to be entirely without complications - and even then, should something go wrong during a home delivery, no certified midwife would hesitate to rush a laboring mother to the nearest hospital. While a woman today can always elect to deliver her baby vaginally without anesthesia, I have yet to hear of an unmedicated caesarian section or of a woman who has refused one at the peril of her own life or her baby's.

While certain conditions of pregnancy such as gestational diabetes and preeclampsia absolutely mandate medical intervention, this does not take into account the myriad of other seemingly benign circumstances that can result in a high risk pregnancy, which should always be monitored by an obstetrician with access to top-notch medical facilities.

Pregnancy connects a woman to her past and her future like no other human experience, and deciding where to draw the line between making childbirth as natural and safe a process as possible, for both mother and child, is a difficult task even today.

Ultimately, it is up to every woman to choose the best of both worlds offered to her. I look at the situation much like I do being able to vote, a right my great-grandmother did not have at my age, or obtaining a reliable form of birth control, which my grandmother did not have access to in her day, or having a safe, legal abortion, an option my mother did not have during her reproductive years - the blessing of being a woman today is not in simply taking advantage of all one's choices, but in having the privilege to make those choices.

by Skip Blaeser


Skip Blaeser is a former attorney and recently converted stay-at-home mom who is enjoying her new opportunities to raise her lively two-year-old son, Kent, as well as pursue her longtime passion for writing historical fiction. She received her A.B. from Princeton University, and her J.D. from the Boston University School of Law.

E-mail Skip Bleaser at:
MarieKDB@aol.com

Addendum

Though due on November 20, Skip Blaeser gave birth to a healthy boy, Frederick Joseph, 6lbs, 8oz, on November 8, 1998 at 4:54 pm at Brigham & Women's Hospital in Boston, MA.

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