 And we're now being recorded. So I'm just going to introduce you to Bill. Dr. Bill McCall has been practicing midwifery since 1984 and has been a midwifery faculty member for over 25 years, first at the Yale School of Nursing and currently at the Penn School of Nursing. Since 1999 he has been the director of the midwifery graduate program at Penn, currently is in clinical practice at the Hospital of the University of Pennsylvania and teaches and conducts research at Penn. Dr. McCall has consulted with universities, ministries of health and midwifery organizations in countries throughout the world, including India, Egypt, Botswana and Guyana, on the education of midwives and the integration of the ancient practice of midwifery into modern healthcare systems. His research is focused on improving maternal child health in developing nations through testing of pedagogical approaches to the training of midwives. He is a fellow in the American College of Nurse Midwives and in the American Academy of Nursing. So welcome Bill. Bill, does your microphone on? Here we go, Bill is typing to us. If you can just bear with us, Bill's obviously having some problems. No, we can't hear you, Bill. Okay. You could go through the audio wizard setup under the meeting tab at the top. You obviously know that you've got to activate your microphone by clicking on the icon. Uh-huh. Looks like you've got the microphone now. You just have to click on the icon to make it go green. I can do it for you. Oh, I've lost it on you. Okay, we're just going to need a few minutes everybody to get over Bill's difficulties if you can bear with us. That's the last resort, Bill. Log on and come back in. Hopefully you can't find another way to resolve it. And if you are using a headset, if you've got the headset all connected up before your computer turns on and before you log in. Just let us know in the text box if you can, Bill, how are you going there and what you're trying. Can see Bill's typing there. Thank you, Denise. Okay, we'll give you a bit more time to get that sorted out, Bill. In the meantime, we might have a bit of discussion here. Denise has already commented on the fact that she'd seen Why Not Home. I haven't seen that yet. Has anybody else seen that? I can hand the microphone to you where you can make some chat in the chat box. Hi, everyone. Just while we are waiting, how about you can think what your biggest challenges for Midwifery are in your country. And we can have a little discussion about that. And we want to get the ball rolling with that one. And if you want to voice your answer, then feel free to raise a hand and I shall give you the mic. Emergency transfers with dignity. That's really interesting. So do you mean from transferring from home to then how you're being treated when you get to the hospital? Legalities between home and hospital and provider rights. And that's something that is a difficulty over here as well and eligible private midwives trying to get access and provider rights to hospitals is a big issue over here. In some states, and territories is better than others. That's what I'm talking about. Oh, hi Bill. This is Bill, can you hear me now? Yeah, we can hear you Bill. Would you like to start your presentation? Sure, I'm sorry I've done all that. Yay! All right, so welcome to Bill and feel free to carry on. Technology has overtaken my abilities. Can you hear me clearly enough? Yes, we can hear you well Bill. Okay, so I'm sorry for the delay but I want to thank everyone at the conference that have set this up. I think it's a wonderful conference so far from what I've heard and I'm going to try and raise through some of these slides because of the delay in getting started. I don't want to delay the next speaker. So, my objectives for today were to review the history of childbirth in 20 minutes or less to offer examples of common pregnancy in childbirth customs and practices throughout the world and then to finally, if we had time, initiate a brief discussion about how childbirth care looks today in the world in the 21st century. If at any time you difficulty hearing me, please stop it. So, what is normal physiologic birth? This is the WHO definition, spontaneous in onset, low risk at the start of labor and remains sudden throughout delivery with the infants born in term and after birth, mother and infant are in good condition. In normal birth, there should be a valid reason to interfere with the natural process. Other organizations have put their own definitions of what a normal physiologic birth is. Some of them are listed here and the ICM said it's a unique dynamic process in which people in maternal physiologies and psychosocial contexts interact. Normal birth is where women commences, continues in complete labor with the infant being born spontaneously at term without any surgical, medical or pharmaceutical intervention. Some people would argue against the pharmaceutical piece there but for now, that's what the ICM definition is. And here in the United States there is a consensus statement put out by three national organizations of lead-wise. It said a normal physiologic labor in birth are those that are powered by the human capacity of women in the fetus. The birth is more likely to be healthy because no unnecessary interventions disrupt the physiological processes. So, how did we go from birth as a natural event to a woman-supported process to the hospital-based medicalized procedure that has occurred over the last 100 years or so. And that's what today's talk is about. We need to actually go back in time and explore just how history and evolution have changed the birth process over the millennia. Evolutionists have shown us that we are by nature primates. A group of animals includes ourselves, apes and monkeys. We began to diverge from our primate cousins about 4 or 10 million years ago. And interestingly enough, our parent's species, homo sapiens or humans came into existence about 200,000 years ago. How does this information help us to understand how we approach pregnancy and birth in the 21st century? Well, here's a graphic of the difference between childbirth for our primate cousins and childbirth for humans. As you can see the size of the heads of the other primates at the time of birth are shown here in gray are considerably smaller than the sizes of the female pellicies, which are outlined here in black lines. Compare that to the size of the human-headed bird as it relates to the dimensions of the pelvis. And we can begin to appreciate why human labor is on average 5 to 30 times longer than that of other primates. And why most primates bear it alone while humans have long had support from others during the birking process. How did this come about? Well, it comes down to two evolutionary forces. One is bipedalism which means standing a wreck or standing on two feet instead of four limbs. And one of the requirements for this position change was the need for a smaller pelvis to keep us from toppling over. The second force which occurred hundreds of thousands of years later was encephalization or with that known as the growth of our brains. As we were able to walk on two limbs instead of four eventually our brains became larger which means it takes a full-term infant a number of hours to move or through this smaller pelvis of the mother. Some people call this evolutionary change the obstetrical dilemma. But actually it leads to a cultural growth of women and labor being supported by other women from their tribes or communities and eventually in most parts of the world with support from midwives. This experience of women helping other women during childbirth began the phenomenon that we know today as socialized childbirth. Now returning to our historical timeline we can see that since the time of recorded history socialized childbirth was depicted or mentioned in Egyptian, Hamer, Grecian, Reigns, and texts. In general, throughout the world the phenomenon of women helping women was a normally bed and had a more spiritual aspect to it over time. Starting to involve goddesses and excluding for the most part male participation. Now I'm going to stop here for a second and acknowledge that this timeline where I'm going to show tonight is based on western history. Certainly the phenomenon of women assisting childbirth and women was apparent throughout the world but the reason that this historical perspective today is focused on the rest particularly Europe is colonialism. Starting in the 15th century and continuing well into the 20th century European nations conquer and annex cultural groups throughout the world bringing with them their uniquely western approaches to daily living and social events and this colonialism goes a long way to explain why childbirth has evolved from a normal physiologic social event to a highly technical medicalized process in many places across the globe today. In a fascinating book shown here called Guns, Germs and Steel Jared Diamond, an American scientist detailed the reason for the spread of western philosophy and culture across the globe. As it says here, people of Eurasian origin, especially those still living in Europe and eastern Asia dominate the world in wealth and power. Other peoples remain far behind and others have been decimated subjugated and even exterminated by European colonialists. And as recently as this year in the Journal of Bulletin and the History of Medicine Quentin Pearson, a historian at Harvard University, applied this historical principle to the practice of obstetrics when he wrote that the links between politics and expert forms of knowledge related to obstetrical care reached beyond domestic affairs to intersect with the imperial and transnational concerns of the country. So returning once again to our timeline, we can see that childbirth continued to be, for the most part, an event that involved women assisting pregnant women and sometimes doing so in a professional manner as midwives. The shift away from this socialized physiological prose began around the time of the spread of colonialism, the spread of Christianity and the growth of what became the practice of medicine. No one date can mark the beginning of this change, but 1492 comes pretty close. Two big events happened that year. Not only did the voyage of Christopher Columbus lead to colonization of the western hemisphere by European countries and the eventual bringing of slaves from Africa to the so-called New World, but 1492 also marked the start of the Spanish Inquisition which symbolized the embeddedness of Christianity in western European culture. Why is that important? While the New Day of Christian influenced after the fall of the Roman Empire in the 5th century, entered a period time known as the Dark Ages, chaos reigned and struggles for power as well as the spread of disease led to the deaths of many Europeans, including pregnant women and children. Eventually Christianity spread with the promise of a better afterlife and the blame for all this illness and death was placed on those who followed the devil instead of God. Indeed, in the first book of the Bible, Genesis, Eve is punished, as it states here, for eating the forbidden fruit in the Garden of Eden and by God making her pains in childbirth very severe and telling her that her husband will rule over her. Thus making childbirth an event that will cause women mispunishment and will give man control over women all in one of the early verses of the Bible. Despite this rather negative view of childbirth, women continue to care for pregnant women throughout the Dark Ages. However, many people were dying at this time because of disease and wars and the cause just seem to have lost Bill there. I'm sure he'll make his way back into the room because he managed to do that last time so we will just hang on and be patient for this fascinating presentation. I think we still have sound, we just don't have Bill. So we're just hanging on to see whether he can reappear. I'm sure he's trying very hard to get back into the room. Absolutely. Do you know what he had as his moment of then tonight? When Williams was on last night and just said Chuck Todd in New York. Hello everyone that's patiently waiting. We have been trying to see if Bill's going to come back into the room for this interesting presentation. In the meantime we might go back while we were waiting before we were discussing what your greatest challenges from midwifery in your country were. We had some comments about the transfers from home to hospital and the issues there with that. So if you're with a woman that's having a home birth and you're transferring through to the hospital and then you're getting a bad experience and the woman's getting a bad experience. What things do you think could help in that scenario? Feel free to raise a hand if you want to chat. Ah Monique let's let me get you the microphone. Hang on a second. That's okay we'll wait for you to type your response. Anyone else have any ideas? Has anyone got any other areas that they think are major issues for midwifery? What are the greatest things for midwifery in your country? What are some really good things that are happening for midwifery? We have in Australia a growing number of group practice setups and contingent care setups across the country coming into some very interesting and remote areas and in the cities as well. Here we go Monique said some of the things that work to help so far having an ob you can transfer to the issue you're trying to find when having the parents report the behaviour to the hospital. Well that's really important isn't it so they can actually unless a complaint happens then things often won't get done. Oh I can see Bill is back. Hi Bill. Hi. Oh that's okay. I'll try to pick up where I think the computer died on me. You were going for the age of enlightenment I think. So the age of enlightenment guides how the dark ages and what that was was both a blessing and a curse. First the blessing. The age of enlightenment plays reason over tradition. An evolutionary idea such as dualism promoted by Descartes promoted the concept that the mind and the body were two unique parts to the human condition and it also led to the development of the scientific method which we see today as a good thing. It brought in the world away from a spiritual look at the body and more into a physiological point of view. And now the curse of the age of enlightenment. His time period saw the growth of medical schools throughout your and eventually your nations of the Americas. These early schools of medicine were limited to the wealthy and to white men. So any scientific studies of pregnancy and childbirth were done by people who didn't actually attend childbirth and most of those who were male physicians. Women assisting women during childbirth was not a part of the new scientific approach and birth became viewed as a biological mechanical process and laid the groundwork for childbirth of intimacy, spirituality and support from women in the community. Meanwhile, colonialism picked up during this time. The men did take control of childbirth advances in knowledge about the human body and diseases and illnesses grew over the next 300 years. In the 1600s wealthy women began to be attended by childbirth, by male doctors from their same social class throughout Europe. In 1634 it's the first known use of forceps by the Chamberlain family in England and then during the 17th and 18th century medical schools for the wealthy classes started in France and eventually grew throughout western Europe and then the United States. The body became more and more viewed as a biological machine, one that could be manipulated for the purpose of healing. And the men as the male doctors were known back then began to intervene in childbirth. And referee came to be viewed as a profession of the poor and the uneducated. New techniques such as anesthetics such as chloroform came into use at Queen Victoria herself used chloroform in 1853 during the birth of her eighth child thus establishing its quote safety for use in childbirth. Increasingly female midwives were attending fewer and fewer births especially amongst the upper middle classes of women in Europe and the United States. What had been a socialized event of women caring for women for over 200 centuries was becoming increasingly mechanized medical event, dominated by men. This returns us to the very real concern of western colonialism. While the industrial revolution that occurred in Europe and the US during the 19th and 20th century flourished so did the spread of ideas and practices from western Europe to existing and former colonies. In addition the outcomes of the two major world wars of the 20th century contributed to the heavy influence of western Europe and the US on many nations and cultures around the globe who unfortunately became dependent on aid from the allied countries for essential care in the form of food, energy and medicine following these wars. Along with this care came the ever-changing view of childbirth as a mechanical process that demanded intervention. The spread of childbirth as a medicalized event intensified in the 20th century and we're going to look for a second here at changes in the United States as an example of how this transformation occurred. At the start of the 20th century less than 5% of women delivered their newborns in hospital settings. With the spread of in 1910 a report came out that was written by then the email was in it Flexner, Abraham Flexner and it basically was a look at how medical schools worked in America and Flexner went around the country looking at all different types of medical schools and decided that the allopathic and osteopathic medical schools those are the philosophies that form the basis what we know today as medical doctors were the only schools that really should be open and anything else such as homeopathy naturopathy and midwifery were suddenly banned in the United States because they were considered practicing medicine without a license. This really put a wedge in the time to keep birth as a socialized event surrounded by women in the community. Birth, pregnancy, and childbirth became more and more treated as a disease state and no longer as a social event. For example Twilight's sleep was started in the United States replacing chloroform for pain control. It dulled the pain of labor and removed any memory from the women's labor and birth but it also caused laboring women to act erratically and without self-control and required that they be restrained to labor and delivery beds in hospitals. In 1920 Joseph Delay, the American obstetrician from Chicago said in the very first issue of what we in the United States call the Gray Journal the American Journal of Obstetrics and Gynecology his quote was labor is decidedly pathologic process. He had long championed the use of forceps and episiotomies at the time of birth and he believed that midwives had no role in caring for pregnant women. By 1939 50% of all births in the United States were now in the hospital. As noted earlier the outcomes of the two major world rulers contributed to the heavy influence of Western Europe and the United States on many nations and cultures around the globe. Modern modern medical developments such as the use of epithelial anesthesia for labor started in 1949 and became more and more popular by the 1970s. In 1956 the first use of ultrasound obstetrics was employed and during the 1960s the practice of continually monitoring a fused heart rate during labor began to receive widespread use through countries that could afford the technology. It's interesting that the use of the C-section rate in the United States in 1970 was only 5% of all births which is staggering when compared to the rate of a third of all births today. This figure however of 5% was soon to change. New forms of Medicaid pain control start to replace twilight sleep but these new anesthetic approaches required women to deliver in hospitals and by 1973 less than 100 years, 99% of American births were taking place in the hospital. It's important to know here that 200,000 years of socialized childbirth appeared to have come to an end. Women no longer gave birth in their homes in communities surrounded by family and friends and supported by midwives but instead were confined to a hospital bed where their pregnancy deliveries were attended mostly by physicians accompanied by obstetrical nurses. By a year of 1988 the C-section rate in the United States had increased 5-fold in less than 2 decades. As physicians recognize the morbidity and mortality associated with technologically invasive vaginal births and as the safety of C-section surgeries improved. So what about socialized childbirth over the last century? Did it completely disappear? Well not really. There were still midwives that were practicing in rural areas where there were very few physicians and in urban areas amongst the newly immigrated poorer populations that had come over from Europe and other regions of the world. And finally amongst African American populations throughout most of America, especially in the south. Many people will recognize these African American midwives by the name Granny Midwives which was a name given to them by public health officials. The moderately wicked profession as it exists today guides start in the United States around the same time that more and more women were turning to hot-toured hospitals and physicians. Trained nurses learned the skills of their lives in such urban places as the Maternity Center Association in New York City found in 1918 and the Royal Frontier Nursing Service in Kentucky found in 1925. Both of these groups of modern midwives as they were called were attending births of neglected women in the United States. The poor of New York City urban life and rural women in the Appalachian Mountains in eastern Kentucky. Despite the strong tide of women receiving care from licensed physicians in hospital settings there were still midwives assisting childbirth either in the form of nurse midwives, granny midwives and apprentice or what became known as lay midwives who practice underground basically despite many roles in the nation outlawing them. There were attempts in the 20th century to continue niche natural childbirth such as the British Obstetrician Grant Dickley-Reed's Childbirth Without Fear that was published in 1933 and then there was the French Obstetrician Bernard Lamaze who published his book, Painless Childbirth with Lamaze Messet in 1956 and then the American Obstetrician Robert Bradley who published his husband coached childbirth known as the Bradley Method in 1965. Ironically these books were written by male physicians who believed paternalistically that their respective approaches to labor and childbirth was the healthiest for women. Let's look about feminism. In 1960s and 70s we saw the re-initiation or rise again of feminism in western countries and less invasive or medicalized approaches to pregnancy childbirth were promoted by several authors. These included Sheila Kitzinger from England who was an anthropologist who argued for women to take back control of their bodies from positions during pregnancy childbirth. In addition, in the Boston area of the United States the Boston Women's Health Collective put out a book, Our Bodies, Our Sells which also challenged women to take control of their own health and bodies. These women that wrote this book challenged the positions and their technological tools to the trade that had become common in the United States at that time. And then finally in 1975 the American midwife in Tennessee wrote her famous book, Spiritual Midwifery which provided a return to the more historical, social, natural and women-centered approach to pregnancy childbirth. So, two major forms historical views of childbirth were basically at a clash in the latter part of the 20th century. In less than two decades these section rates had increased in the United States and many more women were born in hospitals. But there were people that were trying to carry on the 200,000 your cultural tradition of female family friends and midwives caring for women in close to the woman's home and away from the hospital. I feel, can I just give you a five minute warning to wrap it up in that time? I'm so sorry, it's such an interesting presentation. Sure. So, I just was going to I've got a broad race to this last part because I can start it so late. One thing we have to recognize that colonialism and the way it's spread there's approximately 198, 96 nations in the world today and over 8,000 recognized cultures. And common through these are this list here of 12 different aspects of pregnancy that are seen in the world today. For the next slide I have information about each of these which I'll skip through assuming that the slides will be available to anyone once the talk is over. But women assisting women is something that's gone through history over time. The use of spiritual rituals and goddesses are very common throughout the world in many different cultures. The difference between hot and cold states of health are very common in most cultures in the world although not seen very readily here in the west. Similar to that the mind-body balance or yin-yang that comes out of the east is very common throughout the world especially with Asian cultures. Similar to that the balance of four or five elements of the body that are very traditional view even in the western medicine view until the 19th century talked about the balance of different parts of the body. This one I think is an unfortunate one but a very common theme throughout the world is the importance of having a son. And UNICEF addressed this when they said when there is a clear economic or cultural preference for sons the misuse of pregnancy diagnostic tools, mainly ultrasound can facilitate female feticide. That's a topic that we could cover on another talk maybe next year at this time. Many cultures avoid being around death so don't visit cemeteries or attend funerals during pregnancy because it's thought to bring rise to evil spirits. Many cultures respect the evil eye. You can see Hurricane Milton and who's from of course Ireland and Rihanna who's from Barbados both are known to wear this symbol when they're jewelry to protect themselves from the evil eye. Another famous aspect of pregnancy in the world is the labor route which you do not find in typical hospital settings but you do find in birth centers and in many homes throughout the world where there was 10 births. The sacredness or the value of the placenta is common to many cultures in the world whereas in hospitals it's just discarded as part of the after birth. This is another unfortunate one there are many cultures in the world historically and today where a woman does not really attain womanhood or even adulthood until she bears a child and in many places that child needs and these are examples here of some of these folks. Napoleon divorced his wife, first wife where she did bear a son. Henry VIII divorced many women until he got what he thought would be a son. Stalin started in Russia in the Soviet Union a practice that promoted women getting pregnant to increase the population there after the world wars. And even Congress in the United States passed laws in the 1950s that gave tax breaks to women who had children. Finally, postpartum isolation is very important in many cultures in part because of the thoughts related to hot and cold states pregnancy being a hot state and postpartum being a cold state and people are isolated to prevent illness for a range of 30 to 40 days. And this last one unfortunately is not in my list of the 12 things but female gender cutting still continues in many parts of the world and that too is a topic for another discussion. So I'm going to leave you today with just a quick look at this photograph you can see a U.S. delivery room here in 1920 very technical very steel like and everything and that's led to the spread of this approach to childbirth in South Asia. This is a picture I took in 2006 another picture I took in South America in 2007 developing countries have taken this westernized possible version of birth and tried to promote that in their countries but don't have many cases the resources to do it in the way that wealthier nations do. So Richard Smith who is a former editor of the British Medical Journal but only about 15% of medical interventions are supported by solid scientific evidence. This is partly because 1% of studies of medical journals are scientifically sound and partly because many treatments have not been assessed at all. In 2014 he wrote another editorial in the same journal in which he stated quote 20 years later I figured that things are not better but worse. And with regard to childbirth I'll leave you with this quote from the Brazilian obstetrician recorder Jones who said the humanization of childbirth does not represent a romantic return to the past nor a devaluation valuation of technology rather it offers an ecological and sustainable pathway to the future. And at this point if we had time I was going to answer any questions. Thank you for allowing me to race through that I'm sorry about the technological aspects of this presentation and hopefully we can talk about this again in some other form. Thank you so much Bill we did have a couple of questions but we have one out of time for them. People will be able to go through this presentation when it's been recorded I'm just going to go through the last few slides I'm going to turn off the recording