Thursday, July 17, 2014

My oh my, How Times Have Changed

We have now described the fundamental assumption upon which the article "Obstetrics and the Curse of Eve" is based.  According to the authors, a birthing woman is in a category not exactly equal in halachic status to the critically ill patient. Thus, in what they consider to be the classical halacha; on Shabbat one must use a shinuy whenever possible, prior to the final stage of labor one may do nothing other than to call the midwife, and generally speaking only the midwife is called upon to violate Shabbat restrictions.

From here they go on to describe how much things have "changed".  Here are the next few paragraphs:
"Such halakhot could be easily implemented in a society where midwife attended home births were the rule. The only person who, under normal circumstances, had to transgress the Sabbath was the midwife. From a global perspective, home birth is still the norm and hospital birth the alternative. In middle- and high-income countries the opposite is true: the home birth rate in these countries is very low, for example, less than 1 percent in the United States. Where hospital births are the norm, the traditional halakhot about Sabbath observance have quickly become inoperative. 
Even a brief examination of a respected 1979 halakhic compendium will show how much these laws have changed. According to Rabbi Joshua Neuwirth, a woman should travel to the hospital at the onset of the slightest sign of labor. She may carry her possessions with her to the hospital, even through an area without a permitting enclosure (‘eruv) and can be accompanied by an “escort” (presumably her husband), who may also transgress the Sabbath. She may even, under certain circumstances, travel home from the hospital on the Sabbath if in fact she had been mistaken about being in labor.
What sources does Rabbi Neuwirth quote when allowing wholesale transgression of the Sabbath before the final stages of labor? Almost invariably he says, “So I have heard from rabbinic authorities” or refers his readers to the general rule of life-threatening situations (piqquaḥ nefesh). There is no attempt to justify these radical changes; piqquaḥ nefesh apparently speaks for itself."
We have already demonstrated that the fundamental assumption made by the athors is deeply flawed.  That is because the majority of the poskim follow the simple meaning of the words of the Shulhan Arukh and the rambam and the Gemara that state unequivocally that a birthing woman is "B'sakanat nefashot", and that the same laws that apply to any critical patient apply to her as well.  The Maggid Mishna that was quoted by the authors which differentiated between a birthing woman and a critically ill patient was either not accepted by many poskim, or interpreted by the poskim to be refering only to things being done l'yashev da'atah - to calm her fears.

R' Neuwirth, in Shemirat Shabbat K'Hilchatah (SSKH), paskens exactly NOT like the authors of the article would have you assume is the accepted halacha.  In fact, he paskens exactly like many of the poskim we quoted before, and that there is no halachic difference whatsoever between a birthing woman and a critically ill patient.  See SSKH Vol 1, 34:4 note 6 where he states, and I quote:
"see earlier in 32:28 (where R' Neuwirth paskens that one must use a shinuy for every critically ill patient whenever possible), therefore, the law of a birthing woman is the same as the laws of a critically ill patient, in that whenever it is possible, a shinuy must be used."
It is unclear why in the text of the SSKH R' Neuwirth quotes the Maggid Mishna when he states that the pain of birthing is a natural process. However, he provides the source in his note and refers us to the Arukh Hashulkhan and the Mishna Berura.  It is well known that the normal style of the SSKH is to leave this type of detailed analysis to the reader, and simply to provide the sources for someone interested in further investigation.  Regardless, the SSKH is crystal clear, both in 32:28 when he discusses the laws of the critically ill patient, and in 36:4 when he discusses the laws of the birthing woman, that he considers them exactly the same.  He thus follows, not surprisingly at all, the pattern of most poskim throughout the centuries, who did not differentiate between the two.  Unlike the authors who would have you believe that "medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient".

Thus it should be no surprise at all when he allows what the authors consider "wholesale transgression of the Sabbath".  He doesn't need any more sources, as the poskim, especially the Arukh HaShulkhan who WAS quoted by the SSKH, made abundantly clear that even things that are only needed to calm her down, but aren't medically necessary, are permitted on the Shabbat.

The next issue that the authors discuss is the use of male birth attendants.  In summary, they contend that Halakhah in general "severely limited the access of male physicians to women". Traditionally, births were attended by women only, and midwives were the attendents at births.  However, "today most Orthodox women standardly have their babies delivered by male physicians...", and this has been supported by the halachic authorities.  Consistent with the theme of their article, the assumption is made that the reason for this leniency of the modern poskim is that when life is in danger, we can allow transgressions of halachah, including the use of male birth attendants.  In their words, "The male physician is exempted from this rule (the rule prohibiting males from being present at the birth), presumably for reasons of piqquaḥ nefesh."

I will discuss this issue in detail in my next post.

Wednesday, July 16, 2014

Stages of Labor

We now continue with our analysis of the article of interest, "Obstetrics and the Curse of Eve."  The paragraph we took apart in the first post ends with the following statement:
"In fact, before the final stage of labor, no transgressions of the Sabbath were permitted, except for summoning the midwife."
Those readers who have followed this blog from its inception, should be familiar with the Five Principles of Rationalist Medical Halacha.  It should be immediately obvious that the quote above is a gross violation of principle # 2, the "historical corruption principle."  To quote myself, it is of utmost importance when one analyzes a topic in medical halacha, that they "understand how the medical understanding of their predecessors affected the decisions that they made."

They use the term "final stage of labor" which is a modern medical term with a very specific meaning, and they use this term to describe the words of the Shulkhan Arukh.  Their intent in doing this is to emphasize that for most of the process of labor, most transgressions of shabbat were not permitted, other than to summon the midwife.  Only in the "final stage" are we allowed to do anything else if it violates Shabbat.  This further illustrates their contention that the process of childbirth should not warrant as much chillul shabbat as is commonly assumed today.

This is based on a serious misinterpretation of the term used in the sifrei halacha "K'shekora'at leyaled" "when she bends over to give birth".  It is true that one may not violate Shabbat until that time, but when is that time exactly?  Doesn't that sound like the "final stage" of labor?  This seems to support the contention of the authors that only during the "final stage" of labor are we allowed to violate Shabbat.

Nothing could possibly be further from the truth however.  The truth is that the poskim say clearly that we are allowed to violate the shabbat from the time of "Kora'at leyaled", and they describe clearly exactly when that is.  Three examples are given by the gemara in Shabbat 128b-130a, and these examples are repeated in all the sifrei halacha:
  1. When the blood starts to drip
  2. When she sits upon the birthing chair
  3. When her friends are carrying her
I will digress a little to teach you some modern obstetrics, and a little bit about the signs of labor. Every woman experiences labor differently, and there is no one exact way that every labor progresses.  However, there are still some general concepts that can help us understand how labor progresses, and modern medicine is great at dividing things into categories and stages.  

The first stage of labor starts with a closed cervix and ends when the cervix is fully dilated, generally around 10 centimeters.  This is divided for conceptual purposes into two phases, the latent phase and the active phase.  The latent phase is slower, usually less painful, and consists of contractions that are usually farther apart. This phase can last anywhere from two days to just a few hours, and usually is much shorter in women who have had babies before.  This phase usually ends around 4 centimeters when the woman enters into the active phase.  During the active phase of labor, the contractions are much stronger, closer together, and much more uncomfortable.  The cervix dilates quicker, and this phase is usually over in a few hours when the cervix is fully dilated.

The second stage of labor starts when the cervix is fully dilated, and ends when the baby is delivered.  this is often called the pushing stage, as the woman's natural urge to push is very strong, and she will have to work extremely hard to push the baby out.  This can last anywhere from a few minutes to a few hours, depending on all sorts of factors.

It is very important to differentiate between "stages" and "signs" of labor.  Signs of labor include things such as bloody show, the passing of the mucous plug, the "dropping" of the baby, pelvic or low back pressure, and other such symptoms. Stages are what we just described in the previous two paragraphs. The important difference between stages and signs is that not every woman experiences all the signs of labor, and sometimes the presence of those signs doesn't necessarily mean that someone is in labor.  However, every woman does go through the stages of labor, although it could happen at way different speeds, and way different levels of intensity, but the stages always happen.

During the time of chazal, they needed to define the signs of labor that meant the woman is in sakanah.  This was important in order to provide guidance as to when chillul shabbat was permitted. In those days labor was not described in stages like we do today in modern medicine.  Chazal knew very well that there were soft signs that meant labor was imminent, but that the woman was not yet in danger when they happened. They also knew that at some point in time, she transitioned into a stage of sakanah.

When I was a resident, the nurses and residents came up with what we called was the "visual labor check".  We used to joke about how one could usually tell when a couple walked off the elevator towards the front desk whether or not she passed the "visual" test to be admitted.  If her partner (be it a friend, mother, doula, or husband) was holding her as she breathed through her contractions, that was a positive visual test. If she was wet with blood and water, that was a positive visual test.  If she was in such discomfort that the security guard had to wheel her in, that was a positive visual test.  No exam was really necessary to confirm that she was in labor.

The "positive visual test" usually correlates well with the active phase of the first stage of labor, also known as "active labor".  This was of course confirmed when we examined the woman and found out how far dilated her cervix was.  If she was in latent labor, we may send her home, or may send her for a nice walk around the hospital for a few hours, but she did not require admission.  Why? because in the early stages of labor it is commonly understood that there is no serious risk to the health of the Mom or the baby.  However in the active phase, there is risk.  What risks are more common in the active phase? Some examples (but there are certainly many more) include:

  1. Hemorrhage due to abruption (separation of the placenta) or vasa previa (a condition where the umbilical cord can tear)
  2. infection (especially in cases where the labor lasts a long time and the membranes have been broken)
  3. fetal intolerance of labor (the baby may not tolerate the contractions well - which is why we monitor the baby during active labor)
  4. seizures due to blood pressure abnormalities
Now remember that all of these problems are rare, but also recall what we said in the first post on this topic. We explained that although the overwhelming majority of women make it through labor just fine without any medical interventions, the Halacha still paskens that they are all considered pikuach nefesh, so that we can intervene in order to prevent the few deaths that would occur if we didn't intervene.

For example.  We monitor the heart rates of every baby on Shabbat, even though the vast majority of babies would do just fine without a monitor.  Why? because we want to save the one in a thousand that we can find abnormalities in the heart rate.  Another example: We check every woman's blood pressure and temperature, why? because we need to find the one in a hundred that have problems that we can treat! and so on.

Let's go back to the "visual test" from my residency days.  Even though they didn't use the same terminology to describe the stages and phases of labor, Chazal absolutely knew about all the signs of the latent phase of the first stage of labor.  They knew it because it was common knowledge, and everyone knew that it wasn't yet a dangerous time.  But they also knew that when she transitioned into active labor, she was in danger? They knew this as well because it is something that has been observed for as long as human beings have been having babies! What were the signs that she had entered this phase, the signs that any observant person can see? When the blood is flowing, when her friends need to help her walk, and when she lies or sits down in the birthing bed (see Arukh Hashulchan OC 330:4 who explains that sitting on the "Mishbar" does not mean sitting in the bed to push the baby out, but it means when she lies down due to the pain of the contractions).  This fact is so obvious to anyone that has ever seen a woman in labor that one need not even bother explaining it further.

The authors of our article wrote that "before the final stage of labor" violations of shabbat were not permitted.  They assumed that one may not violate the shabbat until the second stage, when the woman is pushing the baby out.  But this is patently wrong.  One may clearly violate Shabbat at the onset of active labor, during the first stage of labor.  Chazal were extremely clear about this, as they observed in nature the same phenomena that we observe today, that the really risky time is the active phase of the first stage of labor.  Just like modern hospitals usually won't admit a patient in the latent phase of labor, chazal also knew that chillul shabbat was inappropriate as well.  It is not necessary to be a modern scientist to know these obvious facts.

"except for summoning the midwife" - of course one may summon the midwife before the onset of active labor.  Because we don't want to wait until the woman is in potential danger before we summon her! She needs to be there before that stage begins!

In short, our authors used a modern medical term, the "final stage" of labor, and assumed that this is what Chazal meant when they said K'shekora'at leyaled".  They therefore concluded that the poskim only permitted chillul shabbat during the final stage of labor, except for summoning the midwife.  This is a mistake. Chazal were referring to the active phase of the first stage of labor.  This is exactly the time when everyone agrees the time of potential danger has begun, and this agreement spans the entire history of humanity, up to and including in modern hospitals.  The modern poskim all agree with what I just wrote, and correctly so. But the authors of our article, not surprisingly, proceed to criticize the modern poskim for this, but that will be coming up soon in an upcoming post...

Monday, July 14, 2014

Why am I so Interested in "Obstetrics and the Curse of Eve?"

This probably should have been the first post in my series on the article "Obstetrics and the Curse of Eve", but I originally thought it would be obvious to my readers why I felt this subject was so important.  However, based on some comments from friends of mine, it seems that many of them didn't understand why I chose to spend so much time on a short article "Obstetrics and the Curse of Eve" in the Hakirah journal.  So let me explain.

I suspect that your rationalist antennae will perk up as much as mine did after you read this explanation.

The modern literature discussing the relationship between Torah and medicine can be divided into several categories.  This may not be an exhaustive list, so I am open to suggestions if you feel I have left something out.  But I would divide it as follows:

  1. The "Laws of  ... " category - This refers to the many handbooks that describe halachot very dryly and in a clear style.  This is permitted, this is not permitted and so on... These books read like instructive handbooks, and generally don't give much instruction regarding the historical, philosophic, or even the halachic developments behind the laws being written.  I am sure many of you have seen these handbooks, and I will not be commenting on these right now, though we probably will at some point in the future of this blog.
  2. The "Medicine of the Torah ..." category - These are the various books describing the medical treatments, cures, and sometimes theories of the Torah, Talmud, Rambam etc.  There are many different angles from which these books approach this topic, some more rationalistic than others, some more mystical than others, and some may be more or less willing to compare the knowledge of the rabbis with the contemporary scientific knowledge. I won't be commenting on this category either during this thread.
  3. The "Ethical guidance of the Torah" category - This includes the vast amount of essays, articles, op-eds, journal entries, and books that have used the Torah sources to develop some sort of ethical or moral idea that the writer believes is "the Torah view" or "the Torah way".  This body of literature assumes that we can learn ethical teachings from the laws of the Torah, and that indeed these teachings can be applied to other areas of life.  We often read about the value the Torah places on things such as the "sanctity of life" or the "responsibility to the other" and so on.  This is the body of literature I am referring to.
  4. The "Torah is a TEA Party Mission Statement" category - This is what you are reading every time an uber-conservative writer uses a verse in the Torah or passage in the Talmud to support his/her ultra conservative views.  This can be about women's role in religion, the Torah's attitude toward homosexuals, or various other topics.  I am NOT taking a position here on these topics, though I will eventually hope to deal with them and others.  All I am saying is that we sometimes find uber-conservatives using what they claim is the Torah to support what are essentially simply just plain old uber-conservative views. This category also includes medical topics, such as abortion, end-of-life issues, organ donation and more. I am not dealing with this category in this particular thread, but I have dealt with some of this in previous threads.
  5. The "Torah is the Huffington Post of the Ancient Times" category - This is the exact opposite of category # 4.  Whenever an uber-liberal expresses his/her uber-liberal views and then uses the Torah sources to back up the idea, he/she is writing literature of this type.  This happens often with environmental issues, social justice issues, and more.  But it also happens often with medical issues, and THIS is what the current thread is about.  I have seen this happen with the scary proliferation of people who don't vaccinate their children, as they may often claim some Torah source for their neglect.  I hope to deal with vaccinations specifically in the future, but I would refer you to the excellent article by Dr. Eddie Reichman about this topic. This brings us to the topic of our current thread, "Obstetrics and the Curse of Eve."
(I hope I have not offended anyone when I used the terms "uber-conservative" or "uber-liberal",  I used them for dramatic effect only. I do not mean to demean anyone who holds these views, in fact, in some cases I may even hold such views myself! I also beg you to not make assumptions about my personal beliefs on a particular topic. I hope that you have learned by now, if you have read anything on this blog, that I freely share my opinions about any topic I am discussing.  However, I will never give in to the temptation of giving out sound bytes of what I think about this or that topic.  If I write about something, it will take me time to develop the sources and reasoning behind my thoughts.  You can then agree or disagree as you see fit.  I am sorry that some may find it boring if they can't get a juicy sound byte from me, but if that's what you want, find another blog.)

The writers of the article of interest are expressing views that are mostly compatible with an entire popular movement in our culture, namely, the "home birth" movement.  It is far beyond the scope of my blog to describe the various controversies relevant to the home birth movement.  However, I can tell you that there are many outspoken critic, including many celebrities, who have criticised various aspects of modern obstetric medicine, especially in the US.  You can follow this link to one of the most influential films called "The Business of Being Born" if you want to find out more about this topic.  This movement has criticised, often rightly, aspects of modern childbirth including using too many drugs, too many surgical interventions, too little personal control over the process, and too much greed.

As an obstetrician myself, I obviously have a lot to say about the topic, and some of it may surprise you. Most importantly, I believe in listening to anyone and everyone that has a reasonable, well researched, and helpful comment or suggestion.  The home birth movement has accomplished a lot regarding the way women in labor are treated, but there are still many differences of opinion, especially between the extremes.  I would be happy to discuss these issues specifically, but for now I want to continue this thread.

The writers of the article are presenting what they believe is a Torah based justification for their belief in home births and the other issues that are related such as drugs in labor and so on.  They may or may not be right, and after you read my blog series I hope you will form your opinion on this matter.

In my first post, I quoted their claim that the Halachic authorities recognized that although a pregnant woman is in a life threatening situation, it is not quite as life threatening as an ordinary critically ill patient.  They made that claim in order to set up their argument that the Torah sources recognize that a birthing woman is undergoing a natural process that is not as dangerous as someone who has an actual critical illness.  They brought some sources that supported this idea, and I brought sources that demonstrated that many, if not most, authorities did not make this distinction at all, and in fact they held that a birthing woman is in exactly the same category as any critically ill patient.

I hope that you now understand why this issue is so important to me, and why it should be so important to anyone interested in rationalist medical halacha.  The way I approach this topic, I believe, should be the way any halachic rationalist should approach anyone who writes an article or book that fits into the "Torah is the Huffington Post of the Ancient Times" category.

We can now move on with our analysis.  I hope you stay along for the ride.

Friday, July 11, 2014

Obstetrics and the Curse of Eve

I sincerely apologize to all of my readers for my prolonged absence from posting on this blog.  The difficulty of posting on a regular basis was something I never realized when I started, but I really will try to make this something more regular.  So please forgive me, and feel free to make suggestions if there are topics that you would like me to cover.  I am going to stop the genetic screening thread for now (with the intention of coming back to it sometime in the future), to deal with an article that was published in the Hakirah Journal in their Winter 2013 issue, Volume 16.  The title of the article is "Obstetrics and the Curse of Eve".

It would benefit the reader to click on the link to the article above, and read it for yourself in order to appreciate what I have to say.  You may also find it worthwhile to refer to the article as I develop my overall theme in my upcoming blog posts.  So let's begin.

The overall theme of the article is to argue that modern obstetrical practices have influenced modern halakhic practice in ways that need to be reconsidered.  The primary four areas that the article attacks are modern halakhic attitudes toward:
  1. Use of drugs in pregnancy and in labor and delivery
  2. The practice of having male attendants during delivery
  3. The ease with which Shabbat restrictions are violated
  4. The practice of hospital birth vs. home birth 
All four of these areas need to be addressed, as they are all extremely important, and I will attempt in this blog series to address them all.

The first topic discussed starts on page 145 of the Journal, and it is called "Birth on the Sabbath". According to the authors:
"Halakhic literature has always recognized that the rules of Sabbath can be transgressed to aid a birthing woman. Nevertheless, medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient (ḥoleh she-yesh bo sakkanah), since “the birthing woman’s pains and strain are natural and less than one in a thousand die in childbirth.” Whenever possible an act of transgressing the Sabbath for the sake of a laboring woman was to be done beshinnui, in a different manner than it would have been done on a weekday. In fact, before the final stage of labor, no transgressions of the Sabbath were permitted, except for summoning the midwife."
The authors quote three sources for these statements.  The Rambam Hilchot Shabbat 2:11, the Maggid Mishna on site, and the Shulchan Arukh OC 330:1. It is of course worthwhile for the reader to check these sources for themselves.  It is clear that the intent of the authors is to give the impression that a woman in childbirth is not quite as much in danger as is the standard critically ill patient.  This sets up their argument advocating home birth as an alternative to hospital birth, and that the use of drugs should be minimized, and so on.  So according to the authors, a birthing woman is halakhic category that is not quite as severe as an ordinary critically ill patient. 

This assertion however, is extremely misleading, and the halachic sources do not at all reflect what the authors claim that they reflect.  It will take me some time to make my point, as this requires a thorough review of the halakhic literature.  I will begin this thread by analyzing the assertion made by the authors of the article in this paragraph, and then I will move on and continue with the rest of the article in a series of posts. Eventually we will be able to summarize our findings and decide what our final approach to this issue will be.  I will also try to remain true to the rationalist approach to medical halacha, and draw from both Torah sources and the relevant scientific and historical sources when appropriate.

Let's start with the Rambam:
"A woman giving birth, her life is considered in danger and one may transgress the Shabbat for her, we can call the midwife from one place to another, and one may cut the cord and tie it, if she needs a light when she is crying out in pain from labor one may light it for her, even if she is blind (one may light for her) because she becomes more calm when there is light even though she herself cannot see.  If she needs oil or any similar thing one may bring it to her.  In any way that one can change (the way it is usually done during the week) then one should change (do it with a "shinuy") at the time one brings it such as her friend can carry a vessel hanging in her hair, but if this is not possible one may bring it the usual way."
And now the Maggid Mishna:
"From the language of our teacher (the Rambam) it seems that a critcally ill person is not included in the need for attempting to do things differently (a "shinuy") but only a midwife must.  This is why he writes that she is "like" she is in danger of death but he did not mention the need for a shinuy when he discussed a person with a critical illness ... And it seems that the reason for this is because the pain of a woman in labor is like a natural thing for her, and not even one in a thousand die from childbirth and therefore they were stringent that one should change the usual way whenever possible but they weren't stringent by a critically ill person ..."
The Shulchan Arukh brings this halachah as well, however the language he uses is a little different, in that he uses the same language as the Tur.  The Tur specifically says that "a Yoledet has the same laws as a critically ill patient" and the Shulkhan Arukh follows suit.  It seems that they are purposefully choosing a language even stronger than the Rambam, as the Rambam only stated that she is considered in danger, while they equate the woman in labor to the critically ill patient.  We will return to this point later.

The Magen Avraham on site brings the Maggid Mishna to explain why the Shulkhan Arukh only requires a shinuy by a woman in labor, but not by an ordinary critically ill patient.  Since the woman in labor is a natural process therefore the Rabbis were more stringent and they required, whenever possible, a shinuy.  The Shulchan Arukh HaRav OC 330:1, and the Mishna Berurah also understood the Maggid Mishna and the Rambam in this way.  They follow the path of the Magen Avraham, and understand that Chazal were more stringent with a birthing woman than a critically ill patient because labor is a natural process and only a small minority of women die in childbirth. 

So all of this so far would seem to support the claim of the authors, that the "medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient."

However, a complete analysis of the poskim actually does not support this contention at all. Allow me to explain.

The primary difficulty that the Maggid Mishna is trying to explain, is why the Rambam mentions by a woman in labor the need for a shinuy, but not by a critically ill patient.  His answer, as described above, was that a woman in labor is a natural process.  Let's think about that for a minute.  The Rambam just stated, following the Mishna and the Gemara in Shabbat 128b, that a laboring woman is considered to be in life threatening danger, and that one is permitted to transgress the Shabbat for her.  If this is true, why then does it matter if it is a natural process or an illness? Even if death is rare, as the Maggid Mishna said, the Gemara already told us that this is sufficient to allow us to transgress the Shabbat!  So why is this any different than an ordinary ill patient?  What if you told me that a particular illness had a 1/1000 chance of death, wouldn't you be allowed to transgress the Shabbat to save such a person?

There must be something deeper here, something that we are missing, and indeed the poskim are bothered by the same questions that we are asking.  So let's see how they deal with it.

Prior to explaining our difficulties with the Maggid Mishna's explanation of the Rambam, we need to mention that this entire discussion is of course only relevant according to the Rambam who seems to differentiate between the woman on childbirth and an ordinary critically ill patient.  The opinion of the Ramban however, is very different.  The Ramban actually brings proof from the gemara that discusses using a shinuy by a birthing woman that one must use a shinuy by all critically ill patients.  The Ramban obviously does not agree with the assertion of the authors that there is "a clear distinction between the birthing woman and the standard critically ill patient".  According to the Ramban, no such distinction exists at all, despite the fact that birthing is a natural process.

Let us return though to our analysis of the opinion of the Rambam and the explanation of the Maggid Mishna.

The Arukh HaShulkhan in OC 330:2 is bothered by our difficulties with the differentiation between the two cases.  He also brings the idea of the Maggid Mishna that labor is a natural process, but he explains it a bit further.  He notes that the gemara only applies this rule of using a shinuy to the lighting of a candle and bringing oil to the woman in labor in order to calm her down ("leyashev da'atah").  That is, since labor is a natural process, most women are calm and able to bear the pain.  However, if the woman requires something just to calm down, though it isn't medically necessary, we can still violate the Shabbat for her, because fear itself can harm her.  However, since it isn't really medically necessary, one should try to use a shinuy.  For things that are medically necessary though, one need not use a shinuy.

Interestingly, the Arukh HaShulkhan can find support for his assertion in the words of the Meiri.  The Meiri in Shabbat 128b describes the need for a shinuy for a birthing woman only in reference to things that are being done LeYashev da'atah.  He describes how things can be done LeYashev Da'atah for a birthing woman even if they require transgressing an Issur De'Oraytah, but then says that a shinuy should be done when possible.  He explains the reason for  requiring a shinuy to calm the birthing woman as opposed to calming a critically ill patient because, "a birthing woman is different because for most of them the danger isn't as great."

At least according to the Arukh Hashulkhan, the author's claim has just fallen apart.  The Shulkhan Arukh and the Tur specifically compare the laboring woman to the critically ill patient, because their laws are exactly the same. Not only can we violate the Shabbat for both of them, we can do it without a shinuy.  Only when we are doing something Leyashev da'atah, only then are we required to try a shinuy first.

These words seem clear from the language of the Rambam himself. As he states:
In any way that one can change (the way it is usually done during the week) then one should change (do it with a "shinuy") at the time one brings it ("Besha'at hava'ah")
This makes it clear that the need for a shinuy only applies at the time of bringing these items, but not when one needs to intervene medically to save her life.

But we are far from finished.  Other poskim as well have dealt with these questions, and it is worth looking at some other approaches.

The sefer Yitzchak Yeranen (R' Elyakim Guttenov d. 1795), is also bothered by the same questions.  He explains the difference based on the well known halachah (see Rambam earlier this perek se'if 3) that when it comes to treating the ill on Shabbat, one should not do it through a gentile or a child, but rather the "Gedolay Torah", the Rabbis themselves should violate the Shabbat, in order to teach the public not to hesitate in similar future situations.  According to R' Guttenov, the same rule applies to a shinuy.  That is to say that in truth, even for any critically ill patient a shinuy should be used.  However, we specifically prohibit the use of a shinuy in order to teach the public not to hesitate in future situations.  By a laboring woman though, there is no need to prohibit the shinuy. That is because despite the fact that the risk to life is there, the chance of death is small, and coupled with only a suspicion that maybe in the future someone might hesitate for a woman in childbirth, that is not enough of a concern to prohibit using a shinuy.

This approach of R' Guttenov also specifically equates the laboring woman to the critically ill patient, only that the Rabbis went out of their way in more critical situations to prohibit the use of a shinuy for the reasons we just described.  Although using R' Guttenov's approach the author's claim that there is a difference between the two cases remains true; it is not because the Rabbi's were more lenient for the birthing woman.  Rather it is because the Rabbis added an extra stringency by more severe illnesses.

The Beit Yehuda (R' Yehuda Ayash d. 1759) in OC 59, is also bothered by our questions, and he strongly disagrees with the entire premise of the Maggid Mishna that there is any difference at all between a birthing woman and a critically ill patient.  According to R' Ayash, the Rambam is of the opinion that one must always do something with a shinuy if possible, and that the Rambam completely agrees with the Ramban in this matter.  It is worthwhile to review his response in its entirety, but for our purposes, our summary should suffice.  Once again, the premise of the authors has fallen short.

The Divrei Yirmiyahu (R' Yirmiyahu Lau d. 1874) also offered an explanation of the Maggid Mishna.  R' Lau explained that the difference between a woman in childbirth and a critically ill patient has to do with the actual presence of illness at the time of the required intervention.  When a person is actually critically ill, one need not use a shinuy when intervening on his/her behalf. However, a woman during the natural process of labor is not ill at this moment, rather she is at risk of becoming ill if we don't intervene.  Thus, says Rav Lau, our interventions are only preventative, not curative, and therefore require a shinuy.  Thus the difference has nothing to do with labor versus illness, as to do an intervention that is only preventative one would always be required to use a shinuy, not just for a birthing woman.

R' Yehuda Navon (d. 1760) , in his sefer Kiryat Melekh Rav, disagrees with the Maggid Mishna in his interpretation of the Rambam, because of the problems we pointed out.  He feels that despite the fact that most women survive childbirth, it is still considered a life threatening situation, just the same as any critically ill patient. Therefore, even for a critically ill patient we would require a shinuy, just like we do for a birthing woman.  However, since in most cases a shinuy for a critically ill patient would cause a delay in care, we therefore never allow a shinuy because we are afraid that one may inadvertantly cause a delay in care. However, by the birthing woman, a delay in how one carries an item to her won't usually cause a delay, so we require a shinuy whereever possible. 

In more modern times, R Yosef Kaddish Bransdorfer, in his sefer "Orah VeSimchah", asks our questions on the Maggid Mishna as well.  He also proposes, like the other poskim we just mentioned, that the Rambam does not differentiate at all between a birthing woman and a critically ill patient. He also mentions the proof from the language of the Rambam when he says, " then one should change (do it with a "shinuy") at the time one brings it ("Besha'at hava'ah")".  He claims, that the only reason why we require a shinuy by a birthing woman, is because labor is something that should be anticipated, so we should be prepared before Shabbat as the end of the pregnancy is approaching. However her status as a person in a life threatening situation is no different at all from the status of any critically ill patient.

R' Bransdorfer points out another interesting observation.  It seems (see the Frankel Rambam for more on these different versions of the Rambam) that the Maggid Mishna, in his version of the Rambam, the "bet" in the word "B'sakanat nefashot" was replaced with a "kaf".  Therefore his Rambam text read as follows:
"A woman giving birth, her life is considered as if she is in danger and one may transgress the Shabbat for her ..."
This is possibly what led the Maggid Mishna to state that:
"From the language of our teacher (the Rambam) it seems ..." 
The "kaf" sounds like it is merely a comparison, but not an exact equation with a critically ill patient, as though there are some inherent differences. However, if he had the wording with a "kaf", like we have in most printed versions of the Rambam today, it would not have led him to believe that there is any difference between the two, as it would have been a clear and unambiguous statement:
"A woman giving birth, her life is considered in danger and one may transgress the Shabbat for her ..."
A much earlier authority, R' Chaim Abulafia (d. 1743) in his sefer Mikra'ey Kodesh, also noted that it seems that the Maggid Mishna had a "kaf" instead of a "bet" in his version of the Rambam.  R' Abulafia goes on to say as well that there is no reason at all to assume that the Rambam disagrees with the Ramban, rather he feels that the Rambam also does not distinguish at all between a birthing woman and a critically ill patient. 

We have thus demonstrated clearly, that the contention of the authors of the article that there is a clear halakhic distinction between a birthing woman and a critically ill patient is not so clear at all. It is true that according to the Magen Avraham, who was quoted by the Mishna Berurah and the Rav Shulkhan Arukh as well, and his interpretation of the Maggid Mishna, that the Halakhah treats a birthing woman as if she is in less of a danger than a standard critically ill patient. However, many other authorities did not understand the Rambam, or the Shulkhan Arukh, in this way.  Certainly the Ramban did not make such a distinction.

This concludes the halakhic discussion for today and my analysis of the first half of the paragraph we started with. The paragraph ends:
"In fact, before the final stage of labor, no transgressions of the Sabbath were permitted, except for summoning the midwife."
I will deal with that statement in the next post.  However, before I sign out, allow me to discuss some non-halachic but very relevant thoughts.

The Maggid Mishna asserts, that "not even one in a thousand die from childbirth".  I find this statement troubling for numerous reasons.

For starters, we are not only concerned about the health of the mother, as we are concerned about the health of the newborn as well.  The halacha states clearly that one can transgress Shabbat even to save the life of an unborn fetus.  Many of the interventions of modern medicine are designed to prevent infant mortality, not just maternal mortality.  To claim that in the time of the Maggid Mishna that the infant mortality rate was less than one in a thousand defies common sense and defies our knowledge of historical reality.

However, this question may not have been relevant to the Maggid Mishna, because in his time there was very little anyone could do if an infant was not born full term and healthy.  However, in our time, when there is a lot that modern medicine can offer, one cannot simply say that “the birthing woman’s pains and strain are natural and less than one in a thousand die in childbirth.”  One must also remember that everything needs to be done to ensure a healthy baby, and the baby is also in a state of life-threatening danger.

Furthermore, I am somewhat baffled by this idea of "less than one in a thousand".  While this have been comforting to the Maggid Mishna, that could be because of the limited interventions they had available in his time.  Don't forget, in the time of the Maggid Mishna, most critically ill patients succumbed to their illness.  Today though, with modern medicine our attitude is usually to fight with everything modern medicine has to offer.  We aren't so ready to accept defeat to "natural processes."

Let me illustrate my point with some real numbers. According to the Israel Central Bureau of Statistics, there were 171, 207 births in Israel in 2013.  If, God Forbid, one in a thousand women died in childbirth, that would mean that 171 women would die every year during childbirth in Israel alone! What a horrible horrible thought.  One in a thousand may sound like a small number, but in a large population, that's a lot of people.  I think most of would argue that everything should be done, even on Shabbat, to save those 171 women's lives, just as one would do for any critically ill patient.

For your reference, according to the US Department of Health and Human Services:
"Maternal mortality in the United States has declined dramatically over the past century. The rate declined from 607.9 maternal deaths per 100,000 live births in 1915 to 12.7 in 2007." 
it is interesting that the 1915 numbers in the US are almost exactly the same as the assessment of the Maggid Mishna.  1,000 per 100,000 births would be "one in a thousand", and the Maggid Mishna said "not even one in a thousand" which is roughly the same as 607.9 per 100,000.  Cool.  But even more cool is the fact that modern medicine has improved upon those numbers significantly, and we haven't even discussed infant mortality statistics yet.

If we assume that 1/7 of all births occur on Shabbat, that's 608 (maternal deaths in 1915) - 13 (maternal deaths in 2007) = 595 women saved every year/ 7 (days of the week) = 85 women per year whose lives we've saved by treating them on Shabbat!  I think that speaks for itself, especially if one of those lives saved was you or your wife.

I will deal with the issue of the safety of home births later, I promise. I am fully aware that much of the decline in maternal mortality in the US is not necessarily because of doctors, drugs, and hospitals etc.  At this point I am just demonstrating (I still do adhere to the famous "five principles" that I set down in my first post) that according to the "common sense principle" of Rationalist Medical Halacha, childbirth is a life threatening situation, even though, in the days before modern medicine, "not even one in a thousand" women died from childbirth.

Hope to see you next time, as we continue our analysis of "Obstetrics and the Curse of Eve".