By Laura Thomas
First of two articles
Seventy-five years ago, two-thirds of American women gave birth at home with no painkillers, often attended by a family doctor, as the tradition of relying on midwives and practical nurses was falling away.
The practice of modern obstetrics was on the rise and the trend toward the majority of births occurring in hospitals was just around the corner as the American Medical Association met in Kansas City in May 1936 and hotly debated the benefits of new childbirth analgesics and how far to go in relieving the pain of childbirth.
According to Time Magazine, Dr. Gertrude Nielsen of Norman, Okla., denounced such pain killing innovations as twilight sleep – a combination of morphine and scopolamine – and a synergistic anesthesia accomplished by injecting a mixture of morphine and Epsom salts into the muscles and introducing a mix of quinine, alcohol and ether in olive oil into the rectum.
“An analgesic that is perfectly safe for both mother and child has not been discovered,” she told the convention. She asserted that fear of childbirth contributed to pain and called for prenatal education to reduce fear: “That is the modern physician’s duty.”
Part of the tumult over the issue had been provoked by articles in the press describing these new drugs and their use. Dr. Buford Garvin of Kansas City observed: “American obstetrics seems to be becoming a competitive practice to please American women in accordance with what they read in lay magazines.”
Childbirth trends change dramatically in the 1960s and 1970s
We could fast-forward to the 1950s when hospital childbirths had become the norm, the pain of the experience was reduced by epidural anesthesia and women relinquished control over the process to the physician. When Dr. Sidney Sharzer joined Permanente in Southern California in 1956, he became an early proponent of change.
During prenatal consultations Sharzer encouraged women to consider breastfeeding, advice which ran counter to the then-popular American pediatric practice of giving “modern” formula. At the University of Toronto, where he received his degree, breastfeeding was still considered preferable: “It provided early immunity and was just the right formula in that there were no problems with digestion and it was the right temperature,” he said.
Formula was seen as a convenience, especially for many women who remained in the workforce after World War II, and it allowed fathers to take part in infant care. It was also heavily promoted by the cereal companies who manufactured it. Most of Sharzer’s patients were bombarded “with a lot of propaganda, or advertising, as we call it,” he said, and resisted his advice. “If you bottle-fed, you were liberated. And, in those days, you were not going to whip out your breast at a shopping center.”
“Liberated” women demand natural childbirth
Ironically, it was the “liberated” women of a later era who demanded a more natural approach to childbirth and support for breastfeeding. Those whispers from the 1930s questioning drug use were getting louder.
“The mid-1960s and early 1970s saw a wholesale consumer revolt against highly structured, hospital-centered prenatal care,” Sharon Levine, MD, Northern California Permanente Medical Group executive, testified before a U.S. Senate committee in 1995. “Rooming in became commonplace. Home deliveries returned. Nurse midwives, who had all but disappeared from the American health system, became increasingly commonplace.
“Maternal-infant bonding became recognized as an essential part of postnatal care. Breastfeeding of infants made a dramatic resurgence,” she said in her testimony against a law to dictate length of hospital stay for new mothers.
Some innovation had already occurred at Kaiser Permanente. In the mid-1950s at Permanente founding physician Sidney Garfield’s behest, the “rooming-in” program began at new facilities in San Francisco, Walnut Creek and Los Angeles. In these early “dream hospitals,” the nursery had been built adjacent to the maternity rooms with slide-through drawers for the babies to be passed in from the nursery through a soundproof wall.
The baby-in-the-drawer configuration allowed a mother to pull the baby into her room to nurse and hold her child as long as she desired. “It keeps mother and baby closer together. Nurses are able to help the new mothers learn better how to care for their infants,” said a Kaiser Permanente newsletter of the era. Most hospitals of the time kept newborns separate from their mothers, under the care of the nursing staff, except for feeding times.
Bringing dad into delivery room
Around 1961, when he took over as chief of service at Harbor City Hospital, Sharzer made a couple of bold moves. He decided to bring fathers directly into the birthing room, and he began to encourage women to use the “prepared childbirth” techniques. He was inspired by British doctor Grantly Dick-Read’s book, “Childbirth without Fear,” which advocated the use of breathing techniques to minimize pain and increase the joy of the experience.
Lamaze breathing techniques were introduced in the U.S. by Marjorie Karmel after she gave birth in France assisted by Dr. Fernand Lamaze, who developed his techniques based on Dick-Read’s. She started an organization in 1960 – now Lamaze International – that currently focuses less on birthing methods and more on achieving a natural childbirth without drugs or technological intervention.
Sharzer remembers his struggle to get these ideas accepted: “The consumers were pushing for it and it was the right thing…husbands should see what their wives are going through.” At the time, fathers were ushered into a waiting room or went home to await a phone call and while some were thrilled to be invited to watch the process, others were less so. The nurses would good-naturedly chide a reluctant father. “They’d say he was a lousy husband to desert his wife at a time like this. They would appeal to his better nature and then insult him,” Sharzer said.
Outside of Harbor City, it was an uphill fight. When Sharzer first suggested the notion to his colleagues at the five other Permanente Southern California facilities, he was voted down 5 to 1. There was a lot of hostility from both doctors and nurses who assumed the fathers would try to get in the way by second guessing the medical staff, he said. But even their resistance couldn’t stop the forces of history. Fathers were finally allowed in delivery rooms at all Southern California facilities by the end of the 1960s.
Sharzer moved on to West Los Angeles in the 1970s and became assistant medical director: “It gave me the opportunity to be innovative.” There, he was able to inspire younger and more progressive doctors to go along with the trend toward treating childbirth as a natural process.
Natural birth after C-section?
Sharzer questioned the long-held “once a cesarean, always a cesarean” policy after he observed countless women scheduled for cesarean arrive at the hospital late in labor and give safe births. “If it’s that dangerous, how come these women come in and two minutes after they hit the bed, the baby comes out naturally?” he said.
Doctors feared that the vertical incision made through the large uterine muscle would rupture during contractions and for years women who had had a cesarean were discouraged from having subsequent vaginal births. But an innovation – the transverse incision made across the lower belly – was introduced that reduced the likelihood of rupture and more doctors began to experiment with allowing women to try vaginal births, under close monitoring.
A five-year study of vaginal births after cesarean deliveries in multiple hospitals showed that reverting to a natural birth process could be successful for many women. “Kaiser Permanente conducted the definitive study concluding that vaginal birth after a prior cesarean section is possible and safe … vaginal births are generally safer and less expensive for the mother and infant,” Permanente’s Dr. Levine told senators.*
Sharzer recalls: “A doctor had to be present all the time and there was a lot of resistance” among the general obstetrical crowd, but at Kaiser Permanente, vaginal birth after cesarean, known as VBAC, was easier to implement because a doctor was always on duty in the maternity ward. “In our setup, it was very good and we were one of the early ones to do VBAC.”
Nurse practitioners deliver prenatal care
In those years, Sharzer also helped establish the first program in Southern California for training nurse practitioners at Cal State Los Angeles and when they graduated, he hired them to work under supervision assisting the doctors with prenatal care.
Retired since 1993, after delivering some 7,000 babies at Harbor City and West Los Angeles, Sharzer attributes the tremendous change in maternity care since 1960 to the Civil Rights Act of 1964: “It also changed the philosophy of equality…and that applied to women in our society. It had a lot to do with female power.”
That piece of legislation guaranteed equal rights to women as well as African-Americans. But women, especially those active in the civil rights and anti-war movements, found themselves relegated to supportive roles to male leadership and many split off and created the feminist movement, founding the National Organization for Women, among others. Health care and childbirth became a major arena in women’s struggle for equality and power over their lives.
Next time: How Kaiser Permanente responded to member demands for shorter postpartum hospital stays.
*Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM. Vaginal birth after cesarean delivery: results of a 5-year multicenter collaborative study. Obstet Gynecol 1990: 76(5 pt 1):750-4.
By Ginny McPartland
Last in a series
The history of nursing at Kaiser Permanente actually begins in 1933 with Betty Runyen, Dr. Sidney Garfield’s sole nurse at the Desert Center Hospital near the construction site of the Los Angeles Aqueduct. Runyen, a young nursing graduate from Los Angeles, was just starting out and looking for adventure.
She was well aware of the early 20th century restrictions on her career options. Her mother had told her she could be a secretary, a teacher or a nurse. Nursing sounded the most intriguing. She became bored with her first job helping to birth babies, and sprung at the opportunity to help launch this pioneering hospital in the desert.
In 1933 nurses were not expected, or even allowed, to perform such a task as starting an IV (tube to introduce liquid intravenously). But Garfield, co-founder of Kaiser Permanente with Henry J. Kaiser, was forward thinking. He had taught Runyen how to start an IV, and the skill came in handy one day when she received an emergency call that one of the workers had succumbed to heat exhaustion. Dr. Garfield was not around, so she drove the ambulance to the job site and immediately inserted a saline IV. The patient quickly recovered.
KP history reflects national trends
Nursing history is also punctuated with challenges related to the nurse’s evolving role on the medical care team and with major changes in technology, including medical equipment and use of computers to record medical notes.
In the 1960s, 1970s, and 1980s care of patients shifted away from the hospital to outpatient settings. Advances in technology made it possible for surgery patients to spend less time in the hospital, and Medicare reimbursement policy revised in 1983 dictated shorter hospital stays. Despite a growing and aging population, the length of stay national average trended down from 8.5 days in 1968 to 6.4 in 1990 to 4.8 in 2005, according to the Centers for Disease Control (CDC).
These changes spawned the same day surgery program that allowed patients to have a procedure without staying overnight. The KP home care program was beefed up to provide surgery and hospitalization follow-up. Outpatient chronic condition management – for the benefit of the patient and the health plan – became ever more important to minimize the time patients had to spend in the hospital. Changes in maternity care also led to shorter hospital stays and an emphasis on family-centered perinatal practices.
New nursing specialties emerge
New categories of nursing have popped up throughout the decades. In the 1970s, the nurse practitioner role was developed to perform many of the tasks formerly done by the physicians. For example, the KP multiphasic or annual physical, initiated in the 1950s for the longshoremen’s union and expanded to the general membership, began to be administered by nurse practitioners working under supervision of physicians. Nurse practitioners were also tapped for well baby care and routine pediatrics visits as medical roles morphed during a critical shortage of medical manpower in America.
With KP’s emphasis on preventive care, its nurses have been called on to create outpatient education programs to help members manage their own health in partnership with their medical care team. Nurses have become specialized in outpatient management of chronic conditions such as heart disease and diabetes, and in providing home and hospice care. Specialized nursing roles have multiplied exponentially over the decades with today’s nurses trained in every aspect of medicine: surgery, intensive care, cardiac care, obstetrics, geriatrics, orthopedics, and the list goes on.