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".


  1. Welcome back! Glad to have another series to look forward to.

  2. I just wanted to point out that 600 per 100000 is 6 in a thousand. And that was in 1915. Clearly the numbers were higher in the Maggid Mishna's time.