Birth: giving life to innovation

Host Walter Isaacson and guests discuss the many ways pregnancy and delivery have changed over the centuries.
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In this episode:

  • Bewitching births (00:00)
  • Giving birth to innovation (04:14)
  • More medicalized birth (10:08)
  • A return to midwifery (11:15)
  • All about IVF (17:57)
  • Transforming prenatal care (22:36)
  • Increasing access (27:01)
  • Creating connections (30:12)
  • The future of pregnancy (31:35)

Birth

Accusations of witchcraft. Administration of chloroform. The experience of giving birth has changed significantly over the centuries. Now, pregnant people have more choices around where to give birth and how to manage pain, while fertility treatments can help others conceive. But, even with the advancements in science and expansion of treatment options in the United States and other places, challenges still arise. Listen to hear how companies are using technology and collaboration to expand access to prenatal care, to strengthen the relationship between obstetrics and midwifery, and more on this episode of Trailblazers.

“The collaboration between the midwives and the obstetricians, it's actually the secret sauce.”

— Dr. Ila Dayananda, OBGYN and chief medical officer for Oula Health

Guest List

  • Birth Tina Cassidy is the author of the book “Birth: The Surprising History of How We Are Born.” @HistoryOfBirth
  • Birth Ina May Gaskin is an internationally bestselling author and founder of The Farm Midwifery Center in Tennessee, renowned for almost fifty years for its exceptional outcomes. Ina May, known as “The Mother of Authentic Midwifery,” is an inductee of the National Women’s Hall of Fame, and is the only midwife to have an internationally recognized obstetric procedure, The Gaskin Maneuver, named in her honor.
  • Birth Jenny Joy is a daughter of Robert Edwards, a pioneer of reproductive medicine and IVF, or in-vitro fertilization. She helped organize the references for his landmark book “Conception in the Human Female”,and also worked at Bourn Hall in the early days as an auxiliary nurse and in the laboratories.
  • Birth Kypros Nicolaides is a Professor of Fetal Medicine at King’s College London. He is one of the pioneers of fetal medicine and his discoveries have revolutionized the field. He is the founder and Chairman of the Fetal Medicine Foundation, a UK charity that funds training of doctors and major research into fetal medicine. @KingsCollegeLon
  • Birth Ryan Kraduel is the VP of Marketing at Nuvo, the pregnancy care company that makes INVU. INVU is a remote pregnancy management platform that combines wearable technology with dynamic cloud-based data capture and visualization, allowing health care providers to do virtual well-being checks with expectant moms from anywhere. @NuvoCares
  • Birth Ila Dayananda is a board-certified OB/GYN and the Obstetrician and Medical Director of Oula, a modern maternity clinic bringing together the best of midwifery and obstetrics to transform the experience of pregnancy and childbirth. @OulaHealth

Walter Isaacson:

It’s June 25th, 1591, and an unruly mob clamoring with excitement has gathered on Castle Hill just below, Scotland’s Edinburgh Castle. Watchers in the crowd, jostling for position, attempting to glimpse the horrifying spectacle unfolding in front of them. A woman named Euphemia Macalzean has been sentenced to death by emulation. Tied to a stake at the center of the wooden platform, the executioner touches a torch to the kindling at Macalzean’s feet. Within minutes, she’s engulfed by flames, her screams echoing through the crowd before she loses consciousness, and finally, succumbs to her burns. Only nine days earlier, King James VI of Scotland, sentenced Macalzean to this unspeakably cruel death, her crime, witchcraft. Earlier that same spring, a pregnant Macalzean went into labor. Her contractions were so severe, she begged her midwife, Agnes Sampson, to place a special birthing stone under her head to relieve the pain. It was an accepted but likely unhelpful medieval technique to ease labor. Macalzean also screamed for any potions that might relieve her pain. Unfortunately, from Macalzean, a servant overheard her cries and immediately reported it to authorities.

At this time in history, there was widespread suspicion of midwives and their techniques, their use of balms, potions and crystals to relieve pain and ease childbirth. Not to mention the long sinister looking fingernail they used to break laboring women’s water led many to believe that these midwives and the women who received their services were practicing witchcraft. By the mid 1700’s, more than 200,000 people had been tried as witches and warlocks, half of whom were ultimately executed for their imagined crimes. The exact number of midwives in that group is unknown, but it’s assumed to be gruesomely high.

Now, 400 years later, women can ask for far more than a stone under their head during labor. In fact, women have more choice than ever in creating a birth plan that works for them, whether they choose a home birth under the supervision of a midwife or prefer an obstetrician administered epidural at their local hospital. Today, the business of being born is thankfully much more humane. Amazing advances in fetal medicine mean more couples are able to conceive, and many high-risk pregnancies are now more likely to be carried safely to term. That’s good news for the approximately 350,000 women who give birth around the world every day. I’m Walter Isaacson and you’re listening to Trailblazers, an original podcast from Dell Technologies.

Speaker 2:

The baby doesn’t always come on the right date.

Speaker 3:

But a Stork leaves it at the door.

Speaker 4:

I want to do everything to ensure me of a normal and healthy child.

Speaker 5:

You have every right to expect one.

Speaker 6:

Your baby is born. The job is done. Congratulations.

Walter Isaacson:

Every woman’s birthing story is unique. There are countless variables at play that can impact pregnancy and labor, but most women would likely agree on one thing, it hurts. Humans are bipeds, meaning we walk on two feet. So the human female birth canal is more narrow than that of most mammals. This in conjunction with our unusually large craniums, makes birth even more difficult for humans. And while other mammals tend to seek privacy during labor, the inherent risk of human birth mean women need help when they’re due. This led to the first major innovation in pregnancy, midwives.

Tina Cassidy:

Being in the presence of another woman, whether it’s a mother, a sister, someone from your tribe, from your community, someone you know, especially one who has been through it herself.

Walter Isaacson:

This is Tina Cassidy, author of Birth, the Surprising History of How We Are Born.

Tina Cassidy:

There’s a lot of knowledge and comfort that would be passed down casually or just part of the environment that you’re in, and that’s basically what early midwifery was. They didn’t even have a name for it. Although midwife means with women.

Walter Isaacson:

Midwifery first attained a degree of credibility in 1609 when Louise Bourgeois, a renowned midwife in service of the French royal family, wrote the first book on midwife teachings, techniques and labor interventions. Shielded from the witch trials by her powerful employer. Her teachings gave the vocation credibility as a trainable skill. With the end of the witch trials in the mid 18th century, midwifery continued to gain momentum and was eventually accepted as a viable and necessary profession. But childbirth still largely remained outside the medical field that began to change with the proliferation of a new birthing tool, forceps.

Speaker 8:

The big moment comes when barber surgeons in England, who were the ones who had licenses to use razors and other sharp knives and other tools as part of their barber businesses were allowed to use forceps on women, and they became what was called barber surgeons. And that’s the bridge between midwifery and obstetrics as we know it today.

Walter Isaacson:

The man who invented forceps was a Parisian named Peter Chamberlain. After moving to England in the late 16th century, he built the first pair to aid with difficult births. Forceps remained his family’s secret for more than a century until they eventually sold the design. In the 18th century, the use of forceps spread throughout England and the medical community realized there was real money to be made from pregnancy and birth. Over the course of a century or so, the role of barber surgeon challenged midwifery and eventually became a field of formal medical study called obstetrics.

One of those early obstetricians was Dr. James Young Simpson. Simpson wanted to cure women of the pain they endured in labor. A recently discovered substance called chloroform, had proven to have analgesic qualities on animals, but was untested on humans. So in 1847, Simpson tested the drug on a laboring woman and hoped for the best. A few hours later, she woke up with a healthy baby in her arms, but the Catholic Church insisted the pain of childbirth was sacred and tried to block the widespread use of chloroform. That is until Queen Victoria now on her eighth child decided she’d had enough.

Tina Cassidy:

She asked her physician to come and help her be put under during childbirth. So he basically just put some ether on a handkerchief and covered her face with it. And so she was anesthetized. And you can draw a straight line from that moment to women getting epidurals today.

Walter Isaacson:

In the following years leading obstetricians swung towards a greater degree of intervention in birth, including induced labor and the use of forceps. Many midwives pushed back against these interventions, deeming them unnecessary, dangerous and an insult to woman’s natural ability to give birth. And so the uneasy union between midwives and obstetricians began to fray.

Tina Cassidy:

There was an active campaign from the early medical community to set up midwives as being ignorant and uneducated and therefore unsafe. And the terrible part about that was that you had lots of people who didn’t have access to the medical community because it was too expensive. And it also dismissed the thousands of years of hands-on knowledge that had been passed down through generations that the midwives had.

Walter Isaacson:

The campaign was successful, and by 1930, midwives were birthing only 15% of American children. Medical innovation had taken women and birth a long way from the teachings of Louise Bourgeois. If forceps were the beginning of more medicalized birth, twilight sleep was the pinnacle. In twilight sleep, women were given a mix of drugs to eliminate pain and wipe their memory, but because they were still conscious, they had to be shackled to a gurney and fitted with a helmet to keep them from injuring themselves,

Tina Cassidy:

But of course, the act of having to wear a helmet and be handcuffed was pretty horrific and traumatic for many women. So when they would wake up, they would have a baby and they wouldn’t know what happened, but they might have bruises on their arms and just feel violated and awful about what had just happened and very confused about it all.

Walter Isaacson:

By 1970, roughly 99% of all births in the US occurred in hospitals. In most states, it was actually illegal to deliver a baby without a medical license, but there was a new wave of women looking for alternatives to the heavily medicalized births of the mid 20th century. Home midwifery practices started popping up around the country. At the forefront of this new movement was Ina May Gaskin.

Ina May Gaskin:

The birth of my first child, which was an unwelcome forceps delivery. I had stated, I’m not afraid of birth, don’t want an anesthesia, but I wasn’t able to convince the doctor. I was in such a euphoric state. I couldn’t have slugged anybody.

Walter Isaacson:

For Gaskin. The birth of her first child was so distressing, she felt the need to find an alternative experience. Soon after she found a community of like-minded women who shared birthing stories and discussed the virtue of home deliveries. Then in 1970, Gaskin got the opportunity to participate in one herself. Gaskin’s husband, a professor and self-proclaimed hippie was about to embark on a cross-country lecture tour with a group of students. Gaskin joined her husband and together they traveled from town to town as a caravan.

Ina May Gaskin:

We’re parked with a caravan of, I don’t know, fifty or so, school bus campers and various vehicles that people living in them and Steven, my husband, was to be lecturing in the auditorium there, it was November, and right there on the shores of Lake Michigan at sundown practically, and an excited young man comes up and says, his wife is in labor, and would Stephen come to help? He said, “Well, I can’t do it. I’m expected in the auditorium in a few minutes.” And I volunteered to go.

Walter Isaacson:

While the mother’s husband delivered the baby, Gaskin made sure she was physically comfortable and emotionally supported.

Ina May Gaskin:

The baby was perfect. He just… Everything worked in the most perfect way possible, almost no blood loss. There couldn’t have been a more perfect birth, but I think there were nine or 10 births along the way. The people traveling with me, there were nearly 300 of us, and I was immediately being called a midwife.

Walter Isaacson:

After the tour, Gaskin and her husband settled in Summertown, Tennessee and founded a commune called The Farm. There Gaskin met Dr. John Williams. Williams had been helping the local Amish community with home births for 16 years and taught Gaskin and other women on The Farm how to perform low intervention births and emergency birthing procedures without the aid of anesthetics. During the first few years at The Farm, Gaskin discovered that natural childbirth could be a spiritual and even euphoric experience. Soon people from the surrounding communities started to come to The Farm to experience her natural birthing process. Then in 1976, a horrific earthquake hit Guatemala, killing more than 20,000 people. So Gaskin decided to head south to help victims of the disaster.

Ina May Gaskin:

There I learned from a Belizean trained midwife who was the director of midwives among the local indigenous part [inaudible 00:15:24], and they had taught her a better way to deal with the very feared complication of shoulder dystocia. When baby’s is PES born, the shoulders are not emerging. She was taught just ask the mother to turn her over to her hands and knees, and that means the pelvis then enlarges the diameter front to back of the pelvis, which is squished together when she’s in the laying back position, now opens.

Walter Isaacson:

Gaskin, brought this technique back to The Farm, taught it to other midwives and published several articles about her finding. Today the technique, now called the Gaskin Maneuver, is widely used by both obstetricians and midwives, but perhaps her greatest victory is that she’s helped show the western world that midwives are a safe and viable birthing option for expectant mothers. A study of more than 1700 midwife assisted births at The Farm was compared to physician attended hospital births. The results showed that the outcomes of low risk natural home births attended by midwives are just as safe, but require less intervention than hospital deliveries. This work was so noteworthy that the medical community eventually realized Gaskin could teach them a thing or two.

Ina May Gaskin:

We had lots of breach babies and twins. We had some births that we recorded. There was nothing more satisfying to me to go in before a bunch of doctors or medical students. And I got invited many times. I did grand rounds in many different places. And then rather than to just talk, I would just put up the video because seeing is believing.

Walter Isaacson:

Gaskin’s first book, Spiritual Midwifery is considered a seminal work presenting pregnancy and childbirth from a natural and spiritual perspective. It sold more than 500,000 copies and has been translated into 12 languages, informing a new wave of midwifery across the globe, an important step to giving women more choice for how they give birth. But for some couples, the decision of how to give birth is still a distant dream because they’re still struggling with the first step of having a child, conception. Infertility affects more than 80 million couples worldwide, and for those wanting to start a family, it can be a heartbreaking state of affairs.

Jenny Joy:

In the 1960s, if you were infertile, that was just your lot.

Walter Isaacson:

This is Jenny Joy, daughter of the physiologist, Robert Edwards, a pioneer of reproductive medicine and IVF or in vitro fertilization.

Jenny Joy:

I mean, there might have been old wives tales cures that you could have tried, but the chance of success was very, very low.

Walter Isaacson:

Edwards became interested in human infertility in 1960 while studying genetics at the University of Cambridge, he was performing early IVF experiments on mice and rabbits when he recognized there was a large population of infertile women and men who would benefit from the treatment. But how could he harvest human eggs to test his theory? IVF is the process of introducing a healthy egg and sperm outside the womb, usually in a Petri dish and implanting the embryo back into the uterus. Edwards’s lab had a steady supply of animal eggs, but human eggs were far more difficult to access. They would only become available if an unrelated and major surgery gave him access to a patient’s ovaries, and that was rare.

Jenny Joy:

And then he heard that this guy called Patrick Steptoe had developed a technique using a laparoscope, and a laparoscope is widely used today and it’s a way of doing keyhole surgery. But my father realized immediately that potentially this could work for harvesting eggs from women. And that was really the start of the relationship that made it all happen.

Walter Isaacson:

Edwards’s hypothesis was right, Steptoe’s. laparoscope proved to be the right tool for extracting eggs from human ovaries. Soon they were successfully fertilizing eggs outside the womb, but IVF was a very polarizing issue in the 1970s, many thought that these test tube babies would be born with abnormalities and the treatments could one day lead to human cloning. Stories in the media claimed Edwards and his team were playing God. Then in November, 1977, a woman who had suffered years of infertility underwent the experimental treatment.

Jenny Joy:

Obviously, it was in a time of intense excitement mixed with apprehension, and the level of media interest in the buildup to the birth had been huge. There were huge problems of patients with no privacy, so it was a very tense time. They also knew that if it was anything but a perfect baby, they would be absolutely crucified by the media. So when my father got the call, they all came back to the hospital later that evening and the magic happened.

Walter Isaacson:

On July 25th, 1978, hopeful Mother Leslie Brown gave birth to a healthy baby girl, Louise Brown, the first baby conceived through IVF. In 2010, thirty two years after the birth of Louise Brown, Dr. Edwards was awarded the Nobel Prize in medicine. To date more than eight million IVF babies have been born, and every year over 2.5 million IVF cycles are performed. But conception is just the first step on the long road of pregnancy. There are many complications and challenges that can arise during this nine month journey. Ultrasound technology was an important innovation to help obstetricians find potential complications early during fetal development, it also helped inspire the man who completely transformed prenatal care.

Kyprianos Nicolaides:

That first encounter with the ultrasound, seeing the moving images of the fetus within the uterus stimulated enormous numbers of questions in my mind.

Walter Isaacson:

This is Kyprianos Nicolaides, one of the world’s top OBGYNs and a professor of fetal medicine at King’s College Hospital in London.

Kypros Nicolaides:

I wanted to know how the babies grow, how they feel, how they develop, how they interact with the mother, whether they become ill and whether there was anything that you could possibly do to cure them. And that was when I decided that I will become a fetal doctor. But there was no such thing as a fetal doctor at that time. I’m now talking about the late 1970s.

Walter Isaacson:

The field of fetal medicine involves screening a fetus for any pre-birth disease or complications, then developing interventions to help improve the outcome for the mother and her baby. In those early days of fetal screening, one thing that struck Nicolaides was the large number of miscarriages occurring for women carrying identical twins. Further study led him to discover a potentially fatal disease called twin to twin transfusion syndrome. Because identical twins share a placenta, in some cases, there is an imbalance of blood flow across their blood vessels causing one twin to get more blood than the other. It’s often a dire prognosis affecting approximately 12% of identical twins. Dr. Nicolaides theorized that if you could introduce a telescope into the uterus, locate the connected blood vessels and separate them with a laser, each fetus would start getting its own equal blood supply, saving them both. It was a risky procedure. Nothing like this had ever been tried before.

Kypros Nicolaides:

I was very pleasantly surprised that once we entered the uterus, we could orientate ourselves. We identified the connecting blood vessels, and then the question was whether by pressing the button that releases this laser wave, the vessels would be cut off or burst or something more serious would happen to the mother. And we were pleasantly surprised again that the vessels were being obliterated without bursting. The first procedure went very well.

Walter Isaacson:

But the initial success of Nicolaides’ experimental procedure was short-lived. During the two subsequent attempts, the babies died.

Kypros Nicolaides:

There’s nothing worse in fetal medicine than watching death. I wanted to stop, but one of my research fellows at the time, he told me, you have to continue, and thank God he pushed me. And then the subsequent cases went well, but many hundreds and then now thousands of women have had this operation in many different parts of the world, and there are very many success stories from women that would have previously lost their babies.

Walter Isaacson:

Nicolaides and his team have also developed screening methods and treatments for premature birth, preeclampsia and spina bifida, saving countless lives.

Kypros Nicolaides:

There’s no greater satisfaction for a person to meet somebody that embraces them and shakes their hand and gives them a kiss and say, “Thank you, 30 years ago, you saved my life.” What a great satisfaction.

Walter Isaacson:

Saving lives is also in the mind of American engineer Oren Oz. Today infant mortality rates across the globe are at an all-time low. Unfortunately, in the US, at least the same can’t be said for pregnant women. Maternal death rates in America have skyrocketed by 50% over the last 25 years, and studies indicate that 60% of those deaths are preventable. Contributing greatly to these numbers is lack of access to prenatal care. This fact was driven home for Oz in 2014 when his wife’s third pregnancy was deemed high risk. In the last two months of her term, she had to visit her doctor 16 times for vital fetal screening. When Oz learned that nearly half the counties in the US did not have a single obstetrician and 55% are without a midwife, he wondered how most pregnant women managed. He soon discovered that they simply don’t.

Ryan Kraudel:

From a clinical outcome standpoint, it’s surprising to say, but the US is actually the most dangerous developed country to give birth in today.

Walter Isaacson:

This is Ryan Kraudel, head of marketing at Nuvo, the company Oren Oz built to address the maternal care gap existing in the US.

Ryan Kraudel:

Unfortunately, there’s expected to be a shortage of around 22,000 obstetricians in the next couple of decades. So again, this issue around access to care is only getting worse.

Walter Isaacson:

Oz and his team hope to change that. They created an at-home monitoring system that can remotely deliver medical grade screening data from an expectant mother to a team of doctors. It’s called INVU.

Ryan Kraudel:

So the INVU technology works by measuring the mother’s heart rate, the fetal heart rate and what’s known as intrauterine activity. Basically, how much is the baby moving around? And so the INVU technology can monitor all of those things remotely and so that starts with the mother using a wearable sensor band. That data is sent to the cloud for processing and analysis. And that processed data is presented to the mother in a mobile app that she can see in real time. And more importantly, that data is presented in real time to her healthcare providers to interpret that data and give an assessment of fetal health.

Walter Isaacson:

INVU uses ECG and acoustic sensors to collect its data. Allowing women in remote locations or those who can’t afford to take time off work, access to the vital monitoring they need. And with its focus on at-home care, there’s a potential for midwives to use it too. It’s a welcome olive branch considering midwives are still incredibly underused. In fact, while midwives have rebounded to attend almost 75% of births in many European countries in the US, they’re still present at only four to 8% of births.

Ila Dayananda:

It’s unfortunate that there has been tension in the past between obstetricians and midwives because it’s a beautiful, beautiful space when we work together.

Walter Isaacson:

This is Ila Dayananda, the Chief Medical Officer at Oula Health. Oula, the first clinic of its kind, has taken steps to mend the uneasy relationship between obstetrics and midwifery.

Ila Dayananda:

Midwives, I truly do believe are the experts in physiologic care and obstetricians, the bulk of our training is to be experts in care for folks when the pregnancy’s a little bit more complicated or when there’s a operative delivery necessary, or where there’s a GYN condition that needs to be treated, and just having that understanding and supporting each other through the process, the collaboration between the midwives and the obstetricians are, it’s actually the secret sauce.

Walter Isaacson:

A lot has changed for pregnant women since Euphemia Macalzean was burned at the stake for seeking pain relief during her labor. Our understanding of pregnancy care has evolved considerably since midwives were unjustly tried for witchcraft, and there have certainly been missteps along the way. But over the last few decades, one thing has become clear, whether a woman wants a home or hospital birth, is struggling to conceive or is having fetal complications, a comprehensive, multi-pronged perspective is best.

Ila Dayananda:

I truly hope the future of pregnancy care for women is a holistic approach to taking care of folks when they are pregnant. There are many different paths here, and the key is to work together to figure out what is best suited for the patient within the realm of providing high quality care and protecting the patient and the fetus as well.

Walter Isaacson:

I’m Walter Isaacson, and you’ve been listening to Trailblazers, an original podcast from Dell Technologies, who believe there’s an innovator in all of us. If you want to learn more about the guests in today’s episode, please visit delltechnologies.com/trailblazers. Thanks for listening.