Elisabeth Bing and an American revolution in birth

On 15 May this year, Elisabeth Bing died at the age of 100. It is no exaggeration to say that during her long life she perhaps did more than any other individual to humanize childbirth practices in the United States. Obituaries and tributes to her rightly celebrate her role as a founding mother of the Lamaze movement in America and a lifelong advocate for improvement in maternity care.

From the vantage point of American obstetrics today, it is difficult to judge her efforts to improve birth a success. Cesarean section rates have been stuck at sky-high levels that approach nearly one-third of all US births — double what the World Health Organization considers optimal, to improve outcomes for mothers and babies. The US is also one of only eight countries to see a rise in maternal mortality over the past decade. That notorious club includes Belize, El Salvador, and South Sudan. Birthing women in the United States have a significantly greater chance of dying as compared to their counterparts in China or Saudi Arabia. Recently characterized as a “national embarrassment,” our infant mortality rate is equally shocking, ignominiously topping the list for OECD countries.

Unquestionably these indicators are nothing short of a scandal. There is an urgent need to reform the maternal health care system to turn these trends around and offer American women the kind of care that is their right. Reversal demands a call to arms to resume the unfinished revolution in maternity care that Elisabeth Bing and others started more than a half-century ago.

Born in Germany, Bing trained in Great Britain as a physical therapist. She became interested in the work of Grantly Dick-Read, who coined the term “natural childbirth” and believed that with proper support and prenatal education almost all women could give birth painlessly without the aid of anesthesia. Though she had her reservations about the effectiveness of the Read method, she began working with expectant mothers to promote his approach in the 1950s after her emigration to the United States.

Amid the postwar baby boom, expectant mothers, if not medical professionals, were receptive to natural childbirth. The Read approach ran very much against the tide at the time, when middle class, urban, white American women routinely received powerful cocktails of anesthetics and sedatives. These drugs left women so confused that they sometimes had to be restrained lest they lash out violently at their caregivers. Women woke to find they had no memory of having given birth, which left many with feelings of disappointment. Setting off a national conversation about the inhumane treatment of laboring women, a letter in 1957 to the Ladies’ Home Journal described the “tortures” of the American delivery room and captured women’s sense of dissatisfaction. Natural childbirth held out the promise of an alternative: a more dignified birth for women, with supportive husbands at their sides.

By the close of the 1950s, Bing began to encounter writings about psychoprophylaxis, a similar method of childbirth preparation and relaxation that originated in the Soviet Union and that was popularized in France by obstetrician Fernand Lamaze. In 1959 she read the book Thank You, Dr. Lamaze, written by Marjorie Karmel, who had been Lamaze’s patient in Paris. Karmel’s description of her experience with psychoprophylaxis was an ah-ha moment for Bing. “I said, ‘Yes, this is it!’ as soon as I read it,” she later recalled. She contacted Karmel and these kindred spirits soon teamed up with obstetrician Benjamin Segal to found the American Society for Psychoprophylaxis in Obstetrics (ASPO), today known as Lamaze International, the largest non-profit organization dedicated to prenatal education.

ASPO was at the vanguard of a revolution in maternity care practices. In the 1960s and 1970s, ASPO’s core mission was the promotion of the Lamaze method, which used patterned breathing and conscious relaxation to enable women to give birth “awake and aware,” as it was described at the time. But the organization also advocated for a suite of interlocking practices intended to empower women and to make American birth more humane. Rooming-in moved newborns from nurseries into the mother’s room in order to facilitate bonding and breastfeeding. Husbands, partners, and, eventually, other loved ones were brought into labor and delivery rooms as birth “coaches” and companions to offer emotional and physical support to mothers and to establish an intimate relationship with the newborn from her very first moment of life. Bing and her colleagues undertook the challenge of educating medical professionals about the lack of evidence to support what were routine, but often unnecessary practices, such as enemas, pubic shaving, episiotomies, and the administration of intravenous fluids. Taken together, these changes worked to shift thinking about childbirth from a medical crisis to a normal life cycle event.

Bing’s revolution is incomplete. Childbirth in the US remains a highly medicalized procedure. Given the poor outcomes relative to other OECD countries, there are serious questions about the wisdom of our high-cost, high-tech, hospital-based, obstetrician-led maternity care. But it is worth remembering how far we have come in advancing maternity care from the “torture” of the 1950s. Many caregivers and mothers aspire to transform birth more fully into a woman-centered, gentle process. There could be no more fitting tribute to Bing’s life than to press on with the agenda that was her life’s work.