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Updated ~ Sunday March 28, 2010 20:35

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Pertinent Historical Background of Childbirth Services in 3 Parts  

links to Part 2, Part 3, and the Citation Key

Part 1  -- The benefits of physiologically-based maternity care for healthy women with normal pregnancies and obstetrical care for complicated pregnancies has been amply documented in maternal-infant statistics. Cost-effective and psychologically sound methods have always been strongly associated with low rates of mortality and morbidity and the long-term well-being of mothers and babies. These positive outcomes for individual families supports important societal goals and their value acknowledged in statements from various physicians of this historical period: 

~© 1925 “The practice of midwifery is as old as the human race. Its history runs parallel with the history of the people and its functions antedate any record we have of medicine as an applied science. Midwives, as a class, were recognized in history from early Egyptian times." [1925-A; Dr. Hardin, MD; p. 347]

 

~© 1913 “The diagnostic ability of midwives is generally good and in the case of many, remarkable excellent. In this respect, the average midwife is fully the equal of the average physician." [Dr. Van Blarcom, MD; 1913]

~ 1911 "Why bother the relatively innocuous midwife, when the ignorant doctor causes many more absolutely unnecessary deaths". [1911-B; Dr.Williams,MD,p.180]

 

~© 1975 “Clearly the midwife seemed to be the safest birth attendant” [Dr. DeVitt, MD; 1975]

Testimony on the efficacy of midwifery care was presented in 1931 to the White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care: Reed (1932) concluded:

~©1932 “...that untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course." (original emphasis)  

~ © 1975 “The passage of midwifery into the mature stream of medical advances has resulted in the parturient women gaining the benefits of (fetal) auscultation, a more complete knowledge of anatomy and asepsis as it developed. Yet, due to the status of women, these advances were kept largely within the circle of male practitioners and thus did not influence the care of the many uncomplicated confinements (managed by midwives) which the physician did not attend.

Conversely, at least in the US, physicians had little contact with midwives and never learned their useful traditions, among them, patience with nature. During the 19th century, obstetricians in England and the US wished to show the scientific nature of their profession. Moreover, in the United States, the dignity of the (obstetrical) profession was thought to be threatened by the practice of midwifery” [Dr. Neal DeVitt, MD, 1975]

~ © 1975 “Whether because midwives provided more skilled care or because obstetricians were too eager to interfere in labor and birth, obstetric mortality rates often rose as ... midwife practice declined.” [DeVitt, MD; 1975]

Irrespective of historical facts documenting the safety of physiologically-based care, it was the intention of organized medicine, starting in the late 19^th century and early decades of the 20^th century, to take over the discipline of midwifery and to replace it with medicalized care as provided by physicians and nurses.

~ ¨ 1820 “Women seldom forget a practitioner who has conducted them tenderly and safely through parturition [childbirth]   It is principally on this account that the practice of midwifery becomes desirable to physicians. It is this which ensures to them the permanency and security of all their other business."

 

"It is one of the first and happiest fruits of improved medical education in America, that  [midwives] were excluded from the practice [of medicine]; and it was only by the united and persevering exertions of some of the most distinguished individuals of our profession has been able to boast, that this was effected.” “Remarks on the Employment of Females as Practitioners in Midwifery – 1820].

The fate of midwives was argued about almost exclusively in the professional journals of physician and public health associations as virtually no attention was paid to the midwife controversy by the popular press during this era (1890-1930). The midwife herself was not privy to those sources which described her as being unwashed, uncouth, ignorant, and inept; nor was she an active participant in the forces that would shape her life and diminish her vocation. All the major acts of this drama were played out before women had the right to vote.

~ © 1975 "Despite what seemed to be early and convincing proof that midwives could provide (maternity) care at least equal to that given by doctors, in addition to the household and public health benefits of the routine (postpartum) care, opposition to the midwife did not abate. Perhaps the facts of the matter were not that important" [DeVitt, MD; 1975]

~ "... the basis of the campaign to eliminate the ‘un-American midwife’ was the self-interest of obstetricians. The primary issue of self-interest was the desire of the obstetricians to expand the influence and increase the status of their specialty. During this period  obstetricians worried constantly about the status of their profession." DeVitt, MD; 1975]

~ ¨1913 "Legalizing the midwife will ...work a definite hardship to those physicians who have become well-trained in obstetrics for it will have a definite tendency to decrease their sphere of influence." [Huntington, MD; 1913]

Of this era, Dr. Neal DeVitt, MD [1975] remarked that:

~ © 1975 "Most of the medical men had too much contempt for the midwife and too little respect for fact. The quality of the debate was poor. Evidence against the midwife was largely anecdotal or unsubstantiated opinion."

Under this medicalized system, nurses in the employ of hospitals and acting under the direction and authority of physicians, would replace the care of the midwife during the many hours of labor. When the birth was imminent, the doctor would be called to come in and attend the “delivery”.  [see attachment

~ ¨ 1915 “Of the 3 professions---namely, the physician, the trained nurse and the midwife, there should be no attempt to perpetuate the last named [midwife], as a separate profession. The midwife should never be regarded as a practitioner, since her only legitimate functions are those of a nurse …." [1915-A; Dr Edgar, MD; p. 104]

 

~ ¨ 1922 “The nurses should be trained to do all the antepartum and postpartum work, from both the doctors’ and nurses’ standpoint, with the doctors always available as consultants when things go wrong;” [1922-A; Dr. Ziegler, MD

“In this plan the work of the doctors would be limited to the delivery of patients, to consultations with the nurses, and to the making of …physical and obstetrical examinations.” [1922-A; Dr. Ziegler, MD, p. 413]

From the obstetrical profession’s perspective, physiologically-based care for “normal” or spontaneous birth was redefined in the early 1900s as unscientific and ‘outdated’. This assertion was part of an effort to elevate the reputation of the obstetrical profession in the eyes of the public and with other doctors.  

~ ¨ 1915  “Engelman says: ‘The parturient [laboring woman] suffers under the old prejudice that labor is a physiological act,’

… and the medical profession entertains the same prejudice, while as a matter of fact, obstetrics has great pathologic dignity ---it is a major science, of the same rank as surgery”.  [1915-C; DeLee, MD p. 116]

Re-defining normal childbirth as abnormal also provided an opportunity to dismiss the care of midwives as outdated:

~ ¨1915 “If the profession would realize that parturition [ childbirth], viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention."[1915-C; Dr Joseph DeLee, MD p.117]

 

~ ¨ 1912 “No attempt should be made to establish schools for midwives, since, in my opinion, they are to be endured in ever-decreasing numbers while substitutes are being created to displace them." [1912-B, p.227]

 

~ ¨ 1912  “The question in my mind is not “what shall we do with the midwife?” We are totally indifferent as to what will becomes of her...” [1912-B, p.225]

Based on the dubious assertion that “childbirth viewed with modern eyes is no longer a normal function”, organized medicine embarked on a campaign to substitute the notion that childbirth properly attended was a “surgical procedure” “performed” by the physician. This was in striking contrast to thousands of years of human history in which clearly it was the mother who gave birth while the normal role of her birth attendants was to help her achieve this important social and developmental milestone and to safeguard her and her baby in case a complication arose. 

~ ¨ 1911 “For the sake of the lay members who may not be familiar with modern obstetric procedures, it may be informing to say that care furnished during childbirth is now considered, in intelligent communities, a surgical procedure." [1911-D, p. 214]

 

~¨1911 “If argument were needed to prove obstetrics a branch of surgery the statistics of the NY Lying-In Hospital for 1909-1910 might be used. Dr. McPherson reports 5,073 patients cared for, of whom 1,037 are classified as "operative", that is more than 20 % or one in every 5." [1911-D, p 214]

The long hours of active labor leading up to the birth was re-contextualized as the “waiting period” that occurred before the physician was summoned to “perform” his important medical work -- the surgical “delivery”.

 ~ ¨ 1922 …..midwives should be trained to do the work of the so called “practical nurses”, acting as assistants to the regular nurses and under their immediate direction and supervision, and to act as assistant-attendants upon women in labor---conducting the labor during the waiting period or until the doctor arrives, and assisting him during the delivery." [1922-A; Dr. Ziegler, MD]

Demoting the central role of labor to a mere “waiting” period devalued the mother’s experience as well as the status of the professional women who provided care during this important time. This pejorative attitude is obstetrician-centric and reflects a professional agenda that reduces the biological, psychological and social value of spontaneous labor and normal birth to the vanishing point. Labor is seen as an inconvenience, an unsatisfactory state of affairs to be gotten over with as quickly as possible, often using drugs to speed labor, so that the ‘real deal’ – the surgical procedure of delivery -- can commence with the use of episiotomy and forceps to short-cut the normal pushing stage.   

Re-defining birth as a surgical event provided a rationale for organized medicine to usurp the assets of midwifery and re-assign them to the obstetrical profession. Since only doctors could perform surgery, all non-physicians (nurses & midwives) would be excluded from providing care under their own authority during normal childbirth.

~ ¨ 1911 “The midwife never has and can never make good until she becomes a practicing physician thoroughly trained;

… that midwives should not be licensed save in those states where they are so numerous that they cannot be abolished at once; and concluding with the third question by showing how midwives can be gradually abolished." [1911-C; Drs. Emmons & Huntington, MD, p. 199

This idea remains at the core of the medical profession’s control of nurse-midwifery, which educates its nurse-midwifery students in the medical model. As graduates, nurse-midwives function primarily within the medical model under the authority of physicians, in a category referred to by organized medicine as “physician-extenders”.

Birth as surgical procedure fundamentally changed the nature of medical education and scientific inquiry into maternity care. Physician researchers no longer studied the physiological management of labor since labor was deemed inherently pathological and anyway, doctors did not attend labors (that was done by nurses). And if a problem arose during labor it was a foregone conclusion that the answer would be drugs or surgery since that was the response for all states of pathology. Once normal childbirth becomes a surgical procedure there is no reason for medical educators to teach, or for medical students to learn, the principles of physiological management that are the foundation of the traditional and contemporary practice of midwifery.

Historically these physiological methods included “patience with nature”, continuity of care, the full time presence of the primary caregiver during active labor, one-on-one social and emotion support, an upright and mobile mother during labor, non-drug pain management (such as walking, therapeutic tough, showers and deep water), right use of gravity during labor and vertical positions during birth.

~©1975 “...in the US, physicians had little contact with midwives and never learned their useful traditions, among them, patience with nature.” [Dr. Neal DeVitt, MD, 1975]

It was convenient for the obstetrical community to reclassify all these “useful traditions” or non-medicalized methods as ‘old-fashioned’, unscientific or even harmful. Any doctor who dared employ what were now deemed “unapproved” or “substandard” methods risked being ostracized, characterized as a quack or accused of negligence or incompetence.  

The next goal was to greatly increase the economic remuneration received by obstetricians for their work. This was a particular problem as midwives received very modest fees – as low as $5 -- where as physicians charged $25. In order to collect a fee five times greater it was necessary to re-contextualize the services of a physician. Organized medicine did this by promoting the idea that pregnancy was a nine-month disease requiring a surgical solution. By 1920 the historical ‘man-midwife’ of the previous 400 years had metamorphosized into an obstetrical surgeon while the mother’s historical role had been reduced to that of passive patient who was assumed to be grateful for having been rescued from the ‘pathology’ of normal childbirth.

By changing uncomplicated childbirth in healthy women from a normal biological function needing little in the way of “doctoring” to a pathological event requiring surgical skills (or as one physician described it “the artificial aid of steel or brawn”) the physician’s role became more central than the mother’s. In the eyes of organized medicine, this elevated the physician from a ‘helping’ role, who merely served childbearing women (‘woman’s work’), to that of a surgeon performing a surgical “procedure” and for which he received a large fee, equivalent to that of gallbladder surgery or a hysterectomy or any other operation. Similar to surgeons performing surgery, obstetricians had (and have) no part in the “normal” care of the patient before or after the ‘operation’. Instead they would only be responsible for the ‘surgical procedure’, while all other aspects of minute-by-minute care would be done by others – nurses and other low-paid assistants who work under the direction of the doctor. 

~ ¨ 1922 “The doctor must be enabled to get his money from small fees received from a much larger number of patients cared for under time-saving and strength-conserving conditions; he must do his work at the minimum expense to himself, and he must not be asked to do any work for which he is not paid the stipulated fee. This means ... the doctors must be relieved of all work that can be done by others—nurses, social workers, midwives...” [1922-A; Dr. Ziegler, MD; p. 412]  

Unfortunately, midwives were not the only group to suffer as a result of this physician-centric configuration of maternity care. By changing childbirth from a biological act “performed” by the mother into a surgical specialty performed by the doctor, it virtually eliminated the mother from the equation, as she was no longer an active participant in her own birth. As a “surgical patient” she was not authorized to have any part in the decision making process. And since she was a ‘not-doctor’, she was “unqualified” to make what were now defined as “medical” decisions.

All aspects of the mother’s care would be determined by “standard procedures”, medical protocols and other medical customs over which she had no control and no opportunity for input. After admission to the hospital she was put to bed, shaved and then put to sleep. She labored under the influence of narcotics (which eliminated the need for on-going labor support!) and was “delivered” under general anesthesia with the use of episiotomy and forceps (which eliminated the need for "patience with nature" or to make right use of gravity).

Under the theory of birth as a ‘surgical procedure’, husbands and other family members were not permitted to be present and so there was no familial witnesses to the events of birth and the quality of care provided (or not) and thus no opportunity to modify or correct its deficiencies. While the surgical treatment of normal birth began in the early 1900s, it still defined the model used for healthy pregnant women in the Cape Canaveral area of Florida (home of the US space program) when I retired from L&D nursing in 1978. While US astronauts blasted off into outer space from a launch pad on Cape Canaveral, orbited earth and even walked on the moon, the wives of these same astronauts were still being given general anesthesia, “generous” episiotomies and forceps deliveries and their astronauts-husbands were still not “permitted” to be present at the birth of their own child.

~ How Did This Come About?

  (Hint -- it had nothing to do with little green men from Mars!)

Part 2 ~ Medical politicians had three primary goals associated with the plan to deconstruct the profession of midwifery and reassign its function to the medical profession. They were to improve medical school education, promote the obstetrical profession’s reputation and increase the economic compensation for services rendered by obstetricians. In the words of obstetricians of the era:

~ ¨1915  “Obstetrics is the most arduous, least appreciated, least supported, and least compensated of all branches of medicine". [Dr. Moran, 1915]

 

~ ¨ 1913 “Legalizing the midwife will ...work a definite hardship to those physicians who have become well-trained in obstetrics for it will have a definite tendency to decrease their sphere of influence." [Huntington, MD; 1913]

One motive for the campaign against midwifery was to defend the poor reputation and abysmal safety record of obstetrics in the US, which was (according to vital statistics and the report of physicians of the day) one of the worst in the developed world. The harder doctors tried to medically control normal birth and improve on Mother Nature through the expanded use of drugs, medical interventions and operative deliveries, the higher the rate of maternal and infant mortality and birth injuries rose.

~§ 1911 “In NYC, the reported cases of death from puerperal sepsis [childbed fever] occur more frequently in the practice of physicians than from the work of the midwives’". [Dr. Ira Wile, 1911-G, p.246]

~§ 1934 “The Committee on Maternal Welfare of the Philadelphia County Medical Society (1934) expressed concern over the rate of deaths of infants from birth injuries increased 62% from 1920 to 1929”. This was simultaneous with the decline of midwife-attended birth and the increase in routine obstetrical interventions, due in part to the influence of operative deliveries. Dr. Neal DeVitt, MD, a 1975 doctoral thesis "The Elimination of Midwifery in the United States -- 1900 through 1935

One physician of the era (Dr. Bolt) identified a rise in maternal deaths of 15% per year for more than a decade and a 44% increase in birth injuries during the period (1910 to 1935) in which physicians displaced midwives and took over the care of healthy women. 

~§ 1922"As to maternal mortality, ...during 1913 about 16,000 women died..; in 1918, about 23,000...and with the 15% increase estimated by [Dr.] Bolt, the number during 1921 will exceed 26,000." [Dr. Ziegler,MD;1922-A]

~§ 1924 “Maternal mortality in this country, when compared with certain other countries, notable England, Wales and Sweden is, according to [Dr.] Howard, “appallingly high and probably unequaled in modern times in any civilized country”.

 

~§.1925 “… in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile." 1925-A; Dr. Hardin, MD, p.347

 

~§ 1925 “… increasing mortality in this country associated with childbirth and the newborn is not the result of midwifery practice, and that, therefore, ...their elimination will not reduce these mortality rates”, [1924-A; Dr. Levy, MD; p. 822]

Serious medical problems in pregnancy and birth at the end of the 19^th century were generally caused by poverty, overwork, ill health and forced childbearing (which is associated with frequent close-spaced pregnancies). These conditions existed simultaneously with the lack of effective treatment for disease, injury or complications of childbearing. It must be remembered that this era was pre-antibiotics, pre-safe blood transfusion, pre-safe anesthesia era and pre-birth control. The background rate of maternal mortality in developed countries was made worse in the United States by the high level of medical and surgical interventions in the 50% of the population cared for by physicians at the turn of the 20^th century. At this point in history, most American physicians were far less trained than midwives but none-the-less performed dangerous operative deliveries on a regular basis. 

~§ 1911 “In general, ...the medical schools in this country and the facilities for teaching obstetrics are far less that those afforded in medicine and surgery;  ..yet young graduates  who have seen only 5 or 6 normal deliveries, and often less, do not hesitate to practice obstetrics, and when the occasion arises to attempt the most serious operations.” 1911-B; WilliamsMD p. 178

 

~ ¨ 1911 “The generally accepted motto for the guidance of the physician is ‘primum non nocere’ (in the first place, do no harm), and yet more than three quarters of the professors of obstetrics in all parts of the country, in reply to my questionnaire, stated that incompetent doctors kill more women each year by improperly performed operations than the ... midwife...." 1911-B; Dr J. Whitridge Williams, MD p.180

The problem was that physicians took over the practice of midwives without any idea of the philosophy, principles or techniques of physiological management. They had no appreciation of the safety and other benefits afforded by physiological methods and no respect for the dangers introduced by medical interference and surgical interventions.

Instead physicians related to the care of healthy childbearing women as an opportunity to develop skills in interventive obstetrics. This was done by routinely using chloroform, episiotomy, forceps and manual removal of the placenta at every normal birth. Anesthetic deaths, PP hemorrhage, infection, brain injury to newborns and long-term gyn complications for mothers followed in the wake of this ill-conceived idea. (Aside: Except for the choice of anesthesia, this was still the routine form of obstetrical care when I retired from L&D nursing in 1979.)

~§ 1937 “Though we cannot make an exact comparison between the maternal mortality in the United States and that in European countries, we can at least make a rough comparison. All who have studied the problem agree that the rate [of good outcomes] for Holland, Norway, Sweden, Denmark is far superior to our own. Why?  … it must be due to a difference in the patients themselves and differences in the way that pregnancy and labor are conducted in the two regions." [1937-A Dr Guttmacher ] p. 133-134

~ 1937 “What about the conduct of labor in the two regions? Here is where the major differences lie. In the first place, ... at least 10 percent of labors in this country are terminated by operation. In the New York Report 20 percent of the deliveries were operative, with a death rate of more that 1 in each 100 of the operated, and 1 in 500 of those who delivered spontaneously.  ." [1937-A]

Obstetricians erroneously assumed that childbirth conducted under sterile operating room conditions would eliminate the great killer of childbearing women and newborns -- a fatal streptococcal infection of the blood stream known as puerperal sepsis or ‘childbed fever’. In their minds this represented a permanent medical cure for this scourge, one so important to public health that it called for 100% hospitalization and 100% care of childbearing women by obstetrical surgeons. From this perspective, it seemed only natural to doctors that childbirth conducted as a surgical procedure would offer the safest and best care. According to history, they were mistaken.

While their intentions were good, the idea that normal childbirth should be abandoned and replaced by the routine use of surgical procedures was actually an experimental hypothesis, that is an "theory" instead of a proven fact. The application of any unproven hypothesis would be considered, under the ethical guidelines for scientific "discoveries", to be a medical experiment. The obstetrical profession was proposing that thousands of years of physiological management be abruptly abandoned and replaced by the hospitalization of healthy women under surgical conditions and the interventionist care of obstetrical surgeons. 

This massive change was purported by the obstetrical profession to make childbirth 'safer'. Normally it would be up to the group that is proposing such a dramatic change to establish that their theoretical basis was accurate and the new methods it generated were safe and effective. For example, obstetricians of the era recognized this principle when it came to the development of their own clinical skills:

~ ¨ 1911 "The paucity of material (i.e. teaching cases) renders it probable that years may elapse before certain complications of pregnancy and labor will be observed ... to the great detriment of the student. 

Moreover, such restriction in [teaching] material greatly hampers the development of the professor and his assistants by the absence of suggestive problems and his inability to subject his own ideas to the test of experience." 1911-B; Dr. Williams, MD p.171

However, this most central aspect of good science, which is to put new theories to the 'test of experience' in a well-conducted research phase, was skipped entirely in the rush to medicalized normal birth. The obstetrical profession went straight to the whole-sale implementation of this untested experimental model, which was turned directly into a wide-spread clinical practice within a single decade and without a single study to verify its efficacy.   

No studies and no vital statistics validated to the superiority of normal birth as a surgical procedure was because it was associated with a dramatic increase in complications, which at times were fatal to childbearing women.

The increased death rate associated with operative deliveries as noted by Dr. Guttmacher in1937 started with the frequent pelvic exams associated with hospital labors, thus exposing mothers to the lethal germs that concentrate in institutional settings and continue to be a source of infections even today. In the pre-antibiotic era of the 1920s and 1930s it was often fatal. In operative deliveries, this exposure to virulent pathogens was combined with the tissue trauma of episiotomy, forceps, the manual removal of placenta and suturing of perineum. Putting gloved hands, surgical instruments or needle and thread into the mother’s birth canal (especially when these instruments cut or bruised her tissue) created the ideal conditions to carry hospital pathogens up into the sterile cavity of the uterus where the raw surface of the recently delivered placenta offered bacteria the perfect pathway into the mother’s blood stream.

The stress of anesthesia and added blood loss associated with episiotomy, operative delivery and manual removal of the placenta all weakened the mother’s immune system and made  her more vulnerable to this lethal infection. The lack of effective antibiotics sealed her fate in all too many cases -- 23,000 maternal deaths in 1918, the majority of them cause by or complicated by streptococcal septicemia. As documented earlier, surgical birth and manual delivery of the placenta (or manual exploration of the uterus after delivery by putting a gloved hand up inside the mother) vastly increased the rate of puerperal sepsis and the rate of maternal deaths.

Unfortunately it was equally easy to conclude that these bad outcomes validated the idea that childbirth itself was intrinsically pathological when actual the problem was the application of emergency interventions to normal circumstances. This false association fueled the campaign to further medicalize childbirth by reinforcing the idea of normal childbirth as dangerous – so dangerous that women died EVEN when “delivered” by doctors and surrounded by the gleaming stainless steel and surgical sterility of an operating room. In the mind of both the lay public and the medical profession, this high mortality rate was interpreted as indisputable proof that normal childbirth was pathological.

~§ 1937 “Let us compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. In Sweden the [operative] interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland ..... it is under 1 percent." [1937-A]

 

“What is responsible for this vast difference in operative rates? ... Analgesics [narcotic drugs] and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted. And midwives are trained to look upon birth as a natural functions which rarely requires artificial aid from steel or brawn. [1937-A]

Luckily for us all, the economic status of the US population slowly improved over the early decades of the 20^th century, contraceptive information became legal and therefore health of the general public improved. This naturally reduced the number of complicated pregnancies and helped to lower the mortality/morbidity rate. In addition the medical discoveries surrounding WWII (safer anesthesia, antibiotics and safer blood transfusion through blood typing) permitted doctors to successfully treat many of the complications caused by operative deliveries. A higher standard of living combined with more effective treatments for the medical complications of childbearing greatly improved the perinatal statistics for the US.

Equally problematic to the reputation of obstetrics in the early part of the century was the pejorative association between obstetrics and “woman’s work”. 

~ ¨ 1915  “Obstetrics is held in disdain by the [medical] profession and the public. The public reasons correctly. If an uneducated women of the lowest class may [provide maternity care], is instructed by doctors and licensed by the State, it [ attendance at a birth] certainly must require very little knowledge and skill ---surely it cannot belong the science and art of medicine." [1915-C; Dr. DeLee, MD p.117]

 

~ ¨1911 “If argument were needed to prove obstetrics a branch of surgery the statistics of the NY Lying-In Hospital for 1909-1910 might be used. Dr. McPherson reports 5,073 patients cared for, of whom 1,037 are classified as "operative", that is more than 20 % or one in every 5." [1911-D, p 214]

While modern-day observers would agree that obstetrics currently enjoys great professional status (obstetrical care accounts for 20% of the entire health care budget),  it must be remembered that the use of the word and concept of “obstetrics” as we know it is a very modern convention. Throughout out the 17th, 18th and 19th centuries the body of knowledge relative to childbearing was called “midwifery” regardless of the gender or status of the practitioner. A doctor who attended births was called a “man-midwife”. The original goal of the ‘man-midwife’ was faithful to the traditions of midwifery as provided by woman practitioners: 

~ 1911 “The function of the physician in midwifery cases is to secure for the women the best possible preparation for her labor, to accomplish her delivery safely and to leave her, so far as possible, in good physical condition; to prepare the mother for, and teach her the importance of nursing her baby and to do everything that is possible to bring this about.” [TAASPIM - Charles Ziegler, 1911]

However, these ideas were significantly more ‘feminine’ than what was typical for the practice of a “medical man”, as physicians of the day preferred to be called. By the end of the 19^th century, this traditional form of midwifery was the poor step-sister of ‘modern-medicine’ and cast aside as a dubious form of “woman’s work” not worthy of the attention of formally-educated medical men. Along with the rejection of midwifery traditions was the replacement of the term “man-midwife” for that of “obstetrician”. 

Doctors of the era described it this way:

~ ¨ 1911 “ ..... the ideal obstetrician is not a man-midwife, but a broad scientific man, with a surgical training, who is prepared to cope with the most serious clinical responsibilities, and at the same time is interested in extending our field of knowledge.

 

No longer would we hear physicians say that they cannot understand how an intelligent man can take up obstetrics, which they regard as about as serious an occupation as a terrier dog sitting before a rat hole waiting for the rat to escape.” 1911-B;Dr J. Whitridge Williams, MD

 

Organized medicine’s answer to mortality rates that were “appallingly high and probably unequaled in modern times in any civilized country” was simple – shoot the messenger!

First on that agenda was a strategy to expand the influence and increase the status of their specialty by deconstructing the reputation of midwifery. This would accomplish three desirable goals at once -- remove the economic competition of midwives, obliterate statistical comparisons between the physiological management provided by midwives and the routine use of medical and surgical interventions by physicians and also free up large quantities of that precious commodity -- “clinical material”. The irrational premise of these efforts is revealed in the following quotes:

~ ¨ 1915 “The midwife has been a drag on the progress of the science and art of obstetrics. Her existence stunts the one and degrades the other. For many centuries she perverted obstetrics from obtaining any standing at all among the science of medicine." Dr. DeLee, 1915-c, p. 114 [emphasis added]

 

~ ¨ 1915 “The midwife is a relic of barbarism. In civilized countries the midwife is wrong, has always been wrong. The greatest bar to human progress has been compromise, and the midwife demands a compromise between right and wrong. All admit that the midwife is wrong." [1915-C; Dr Joseph DeLee, MD. p. 114]

~ ¨ 1911 “I should like to emphasize what may be called the negative side of the midwife. Dr. Edgar states that the teaching material in New York is taxed to the utmost. The 50,000 cases delivered by midwives are not available for this purpose. Might not this wealth of material, 50,000 cases in NY, be gradually utilized to train physicians?" [1911-D, p 216]

The next step of this plan was equally bold -- to “re-invent” obstetrics as indispensable and above reproach. By discouraging public oversight and external scrutiny, it would essentially exclude obstetricians from accountability for the high maternal-infant mortality rate in the US. Unhampered by an objective standard of efficacy (cost-effectiveness combined with safety) they could (and do) own the maternity care system in the US and eventually exported American-style, interventionist obstetrics around the world.

~ ¨ 1911 “We believe it to be the duty and privilege of the medical profession of American to safeguard the health of the people; we believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth.

The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public." [Boston Medical & Surgical Journal, Feb 23, 1911, page 261]

The prejudicial process that dominated the obstetrical profession is known as a "pre-cognitive  commitment" and describes making a commitment to a plan of action prior to having full or accurate information. Contemporary obstetrics is still predicated on this erroneous "pre-cognitive commitment" set into place during this time period and remaining unexamined by mainstream medicine today.

In order for medical politicians of this historical era to have pursued this dubious course of action, two crucial facts had to be ignored. First, that childbearing itself in healthy women is not fundamentally dangerous and does not routinely benefit from surgical skills. It was poverty, overwork and forced childbearing that were the genuine problems facing mothers and babies of that time period and which contributed to an alarming rate of death and disability. Secondly, it failed to account for the serious harm -- including death for both mother and baby -- which could and did result from the routine use of medical interference. Most unfortunate of all, these harmful interventions did not address the underlying health problems of poverty and overwork or contribute to the greater goals of public health in a more profound and long lasting manner.

The great improvement in maternal-child health that has occurred over the course of the 20th century is primarily the result of an increased standard of living -- sanitation, education, a better diet, adequate housing, improved working condition, appropriate access to medical care when needed and the safety net of social programs combine with wide-spread availability of effective contraception. Only a tiny portion of this improvement can be attributed solely to obstetrical interventions. In many instances, the underlying cause of problems later "cured" by obstetrical procedures were actually caused by poverty and exploitation.

Clinical Material, the ‘Flexner Report’ and the ‘Midwife Problem’

 

Another important aspect of the plan to redefine normal childbirth as a surgical procedure had to do with efforts by organized medicine to increase the “clinical material” (teaching cases) available to medical students. This reflected the low esteem & poor reputation that obstetricians suffered under, a situation created by inferior medical training as contrasted with Europe (and pointed out in very unflattering terms by the 1910 Flexner Report). This resulted in high level of mortality associated with dangerously poor obstetrical care and ill-conceived operative interference.  

The Flexner Report, published in 1910 and funded by the AMA, severely criticized the lack of clinical training in U.S. med schools, especially as contrasted with the highly-prized medical training available on ‘The Continent'.

~§ 1911 “The story of medical education in the country is not the story of complete success. We have made ourselves the jest of scientists through out the world by our lack of a uniform standard. [1911-C, p. 207]

~§ 1911 "In 1850, Dr. James P. White, introduced into this country clinical methods of instruction in obstetrics. Yet, during the following 62 years... our medical schools have not succeeded in training their graduates to be safe practitioners of obstetrics." 1911-B; Dr. Williams; MD

~ "After 18 years of experience in teaching what is probably the best body of medical students every collected in the country -- the student body at the Johns Hopkins Medical School for the years 1911-1912 .... -- I would unhesitatingly state that my own students are absolutely unfit upon gradation to practice obstetrics in its broad sense, and are scarcely prepared to handle the ordinary cases." [1911-B; Dr. Williams, MD p. 178]

~ "A priori, the replies seem to indicate that women in labor are safer in the hands of …. midwives that in those of poorly trained medical men. Such conclusion however, is contrary to reason, as it would postulate the restriction of obstetrical practice to the former (midwives) and the abolition of medical practitioners, which would be a manifest absurdity." [1911-B; Williams, MD]

 

~§ 1975 “In 1911, the great American obstetrician, J. Whitridge Williams, (original author of "Williams Obstetrics"), completed a survey of obstetrical education in United States medical schools. Dr. Williams found that more than one-third of the professors of obstetrics were general practitioners.

 

~ “‘Several accepted the professorship merely because it was offered to them but had no special training or liking for it.’ 13 had seen less than 500 cases of labor, 5 had seen less then 100 cases and one professor had never seen a woman deliver before assuming his professorship. Several professors of obstetrics were not able to perform a Cesarean section. [Dr. DeVitt, MD, 1975]

~§ 1975 “In 1911, the great American obstetrician, J. Whitridge Williams, (original author of "Williams Obstetrics"), completed a survey of obstetrical education in United States medical schools. Dr. Williams found that more than one-third of the professors of obstetrics were general practitioners.

 

“‘Several accepted the professorship merely because it was offered to them but had no special training or liking for it.’ Thirteen had seen less than 500 cases of labor, five had seen less then 100 cases and one professor had never seen a woman deliver before assuming his professorship. Several professors of obstetrics were not able to perform a Cesarean section. [Dr. DeVitt, MD, 1975]

A dramatic increase in clinical material was to be achieved by taking over the population of childbearing women that here-to-fore had been cared for by midwives.

~ ¨ 1912 “It is generally recognized that obstetrical training in this country is woefully deficient. There has been a dearth of great obstetrical teachers with proper ideals … but the deficiency in obstetrical institutions and in obstetrical material for teaching purposes has been even greater. It is today absolutely impossible to provide {teaching} material.” [1912-B, p. 226

 

~ ¨ 1911  "No one can read these figures without admitting that the situation is deplorable, and that the vast majority of our schools are not prepared to give the proper clinical instruction to anything like the present number of students. ....

 

The paucity of material (i.e. teaching cases) renders it probable that years may elapse before certain complications of pregnancy and labor will be observed ... to the great detriment of the student. Moreover, such restriction in [teaching] material greatly hampers the development of the professor and his assistants by the absence of suggestive problems and his inability to subject his own ideas to the test of experience." 1911-B; Williams, MD p.171

 

~ ¨ 1912 “When we recall that abroad the midwives are required to deliver in a hospital at least 20 cases under the most careful supervision and instruction before being allowed to practice, it is evident that the training of medical students in obstetrics in this country is a farce and a disgrace.”

 

“It is then perfectly plain that the midwife cases, in large part at least, are necessary for the proper training of medical students. If for no other reason, this one alone is sufficient to justify the elimination of a large number of midwives, since the standard of obstetrical teaching and practice can never be raised without giving better training to physicians." [1912-B, p.226]

Socially-speaking, this was a lower class of women (often immigrants or ethnic minorities) who were thought to be a more “appropriate” source of clinical material than the private paying patients of physicians. American-born, upper class white women would never allow “4-6 medical students” to do sequential pelvic exams or practice applying forceps and performing episiotomies as a part of their medical education.

~ ¨ 1912  “the actual figures show that in 25 schools, each student see 3 (deliveries) or less, in 9 schools, 4-5 cases and in 8 others, 5 or more cases, while in some of the smaller hospitals this is possible only by having 4-6 (medical students) examine the each patient..” [1912-B, p. 22

Midwives and midwifery training were both considered expendable in exchange for the "greater good" of improved clinical training for physicians, as defined by Dr. Joseph DeLee’s paper on "Ideal Obstetrics".

~ ¨ 1911 “Until we have solved the problem of how NOT to produce incompetent physicians, let us not complicate the problem by attempting to properly train a new class of practitioners. The opportunities for clinical (i.e. "bedside") instruction in our large cities are all too few to properly train our nurses and our doctors; how can we for an instant consider the training of the midwife as well?" [1911-C, p. 207]

He acknowledged that closing the training schools for midwives meant that untrained or inadequately trained midwives would be unable to prevent otherwise “preventable” deaths among the patients they served. However, he considered the plan to eliminate midwives so crucial to his “obstetrical ideal” that loss of human life among the “lower-class” of women cared for by midwives was just one of the prices to be paid for the advancement of science.

~ ¨ 1912 “It is, therefore, worth while to sacrifice everything, including human life to accomplish the (obstetric) ideal ". Dr. DeLee, 1915  

~ ¨ 1911 “If such conclusions are correct, ...[we must] insist upon the institution of radical reforms in the teaching of obstetrics in our medical schools and upon improvement of medical practice, rather than attempting to train efficient and trustworthy midwives." 1911-B; WilliamsMD p.166  

 

~§ 1975 "With these results of the midwifery surveys and of Williams’ survey of obstetrical education, the debate over the future of the midwife began.  Against the midwife were obstetricians who favored immediate abolition of the midwife no matter what the consequences [most were from Boston - Noyes, 1912], or who favored gradual abolition through stricter regulation [Williams, 1912; Ziegler, 1913].

 

For the midwife, were public health officers and Southern obstetricians who realized that the midwife could not be eliminated immediately and thus  wished to train her [Nicholson, 1917; Hardin, 1925], and a few physicians [most notably Abraham Jacobi, 1912] who wished to establish midwifery schools in the United States to make the midwife a permanent institution in the US as it already was in Europe." [DeVitt, MD, 1975]

Midwifery Training Schools

Many physicians of the day insisted that midwives were ignorant, dirty and dangerous. The fact that midwives of whatever educational background still had better statistics than physicians only served to infuriate the medical establishment. In truth, a significant number of midwives (40-60% in cities on the eastern seaboard) had been formally educated in reputable European schools of midwifery, some of whom had been training midwives for 200 years. These highly-regarded training programs required midwifery students to manage a minimum of 20 deliveries under the watchful supervision of their instructors. There was also a school of midwifery started in NYC at Bellevue Hospital in 1911.

~§ 1911 "New York City is entitled to the honor of having established the first School for Midwives in the United States under municipal control."[1911-G] ......

 

~§ 1915 "Each midwife must witness or assist in at least 80 deliveries and in addition, deliver a minimum of 20 cases. When this course is completed, a practical and oral examination is given by a visiting obstetrician and if the candidate successfully passes these a diploma is granted." [1915-A; EdgarMD p. 98]

At this same time, medical students were only required to observe 6 deliveries and often graduated from medical school with virtually no clinical  experience. The common complaint by public health officials was that newly graduated physicians offered maternity care without sufficient clinical training, routinely attempted to hastened birth through the injudicious use of drugs and surgical instruments and frequently did not follow public health regulations

In contrast, health officials and other physicians observed that midwives as a group were co-operative in upgrading their skills, followed the directives of public health officials, and had better compliance with laws requiring treatment of newborn eyes and filling of birth certificates than physicians. While it was true of a minority of midwives were untrained and or unskilled, whatever real or imagined deficiency in midwifery education and practice that may have existed during this era, the obvious ethical response would have been to support the establishment of midwifery training programs and regulation of practicing midwives.

A Few Good Men and Women Physicians who knew better

Obviously not all physicians of the day were fooled by political motives masquerading as a high ideals. While medical politicians promoted massive amounts of misinformation, a small number of midwife-friendly physicians and public health officials who knew first-hand of the excellent success of responsible midwives were vocal in their support of midwives.

 ~ ©1911  "The practice of midwifery dates back to the beginning of human life in this world. At this supreme moment of motherhood it is probable that some assistance has always been required and given. Its history runs parallel with the history of the people, and its functions antedate any record we have of medicine as an applied process. To deny its right to exist as a calling is to take issue with the eternal verities of life. The only points upon which we may argue are the training required for its safe and lawful practice, and the essential fitness of those who follow this calling requisite for the safeguarding of the mother and child." [1911-G; Josephine Baker, MD, p. 232]

It is thanks to the honesty of these physicians and their concern for childbearing women and babies that we have the documents and statistical records which expose these institutionalized prejudices against midwives. Many of these midwife-friendly physicians managed midwifery training programs or were public health officers. Their well-documented criticisms were recorded in medical journals of the day, complete with tables of compelling statistics clearly demonstrating the scientific basis of their observations. Unfortunately, this crucial information was uniformly ignored by medical politicians.

In 1915 Dr. P.W. van Peyma, Buffalo, NY, had 40 years of experience working with midwives and was a member of the Board of Examiners in Midwifery for 25 years. He stated that:

~ ©1911 "The essential difference between a midwife and a physician is that (physicians) are free to hasten delivery by means of forceps, version, etc. This, in my experience, results in more serious consequences than any shortcomings of midwives. 

 

...Time is an element of first importance in labor, and the midwife is more inclined to give this than is the average ... physician. ... The present wave of operative interference is disastrous. ... The situation would not be improved by turning (the clients of midwives) into the hands of such medical men...".

~ “Obstetric training in the medical colleges is recognized as inadequate, [yet] there is no voice raised to eliminate the doctor from the practice of midwifery. Dr. Hirst is at present circularizing the State Board of Health to establish a standard for obstetrical experience for (physician) candidates for licensure, and ... he suggests the personal delivery of 6 women. In NYC, the midwife is required to have the personal care of 20 women before a permit is granted to her. [1915 Dr. P.W. van Peyma, Buffalo, NY]

 

~ ©1911 “The irregular practitioner of medicine is still permitted to be an obstetrician with an experience that is inferior to that possessed by more than half of the midwives. Let us be fair to the midwife, I say, and if she is below the ideal we have for her, though we have never crystallized that ideal into law, let us give her the opportunity to rise and educate herself under proper supervision." [1911-G; BakerMD, p. 224]

 

~ ©1911 Dr. Ira S. Wile, New York City: "But it is manifestly unfair to criticize the lack of an educational standard which has never been established. When nurses were of the Sairey Gamp-type, elimination was not the cure. When apprenticeship was the open sesame to the practice of medicine ...elimination was not the cure. Education, training, regulation and control solved these problems just as they will solve the midwife problem. Dr.Wile, 1911

 

Establish an educational standard, provide sufficient facilities for giving the adequate training, secure the legislation essential to provide the supervision and control and then raise the standard of the midwife so that no further fault may be found. Let us to fair to the midwives and their patients. Let there be an evolution of this class of public servant and not a hasty attempt to check their possible development."

“First, Catch Your rabbit"
Solving the "midwife problem" by manipulating the legal & legislative system 
 

The voices of reason were few, unknown by the public and totally ignored by the organized medicine. Medical politicians and physician opponents of midwifery went about solving the “midwife problem” by passing restrictive laws regulating midwives as a tactic for suppressing and, it was hoped, eventually abolishing the independent practice of midwifery. The strategy was simple – wherever possible outlaw the independent practice of midwives (i.e., non-nurse midwifery) directly OR craft laws that midwives could not comply with (i.e.. snares for the unwary).

~ ¨ 1912  “...the great danger lies in the possibility of attempting to educate the midwife and in licensing her to practice midwifery, giving her ...a legal status which cannot ...be altered..."[1912-B, p.222 ]

 

~ ¨ 1915 “Do ophthalmologists favor a school for the instruction of optometrists...? Why not train the chiropractor and Christian Scientists also?" [1915-C; DeLeeMD p. 115]

These tactics were referred to by medical politicians of the day as “First, catch your rabbit” and were originally put into motion in 1910. When a midwife violated the licensing law, she could be prosecuted and her license revoked, permanently stopping her from practicing via a count ordered injunction.

~ ¨ 1911 “It is quite possible by strict educational requirements, by imposing certain qualification as to the experience and training, AND IN OTHER WAYS, to restrict the practice of midwifery to such a degree as to amount to practical abolition. Such a method is necessarily more slow than direct abolition. It can be carried out, ... according to the forms of law." [1911-E, p. 225]

 

~ ¨ 1911 “Have the license to practice be an annual affair based on the record for the previous years. Then by gradually raising the standard and providing dispensary care (free prenatal clinics and home birth services by medical students), .. the problem in a few years would simply (solve) itself." [1911-C, p. 210]

 

~ ¨ 1911 “In states where the midwife is practically unknown, it should be seen to that the Medical Practice Law excludes the possibility of midwives practicing within the limits of the state. In states where the midwives are not forbidden by law and are numerous, a well  organized license and regulation system should control those in practice. Outline for them the minimum standard for their cases and enforce at least this standard by taking away the licenses of those who violate the law. Renew the old licenses every year and issue NO NEW ONES. Thus the midwives will gradually be excluded from practice… by the lapse of time." [1911-C, p. 209]

 

~ ¨ 1907 “..the best argument for a state law, namely, because a midwife once convicted of a crime would afterwards be disqualified to practice by reason of said conviction. First catch your rabbit." [1907, Dr. Mabbott; American Journal of Obstetrics]

Propaganda ~ a tool for the hearts and minds of the public

In conjunction with legal and legislative efforts to deconstruct the legal practice of  midwives, there was also a propaganda campaign to win over the hearts and minds of the public. Medical propaganda centered around the false idea that physician-attended deliveries were safer than giving birth with a skilled midwife. This was not true but the statistical information to refute it was not generally available to the lay public. This propaganda campaign misrepresented the dangers of childbirth and inflated the abilities of medically-based care to eliminate them, while denigrating midwives. In the following quote Dr. DeLee answers the question of how this campaign to "elevate the public conscience" was to be carried out and what exactly the goal of it was to be:

~ ¨ 1911 "How can this be done? Let us begin with the Women’s Clubs in the United States. Let us tell them of the facts we have learned here today. The Woman’s Clubs in the US are an enormous power, and they are growing more powerful in the civil and social betterment of this country. If we can disseminate among the women of our land the facts regarding obstetrics, there will rise an undeniable clamor for good obstetrics. The public will be forced to furnish the materials, and the patients for the proper instruction of the doctors. They will build maternity hospitals the equal, if not the superior of any surgical hospital." [1911-B; DeLeeMD]

~ "When public opinion has thus been raised and educated regarding obstetrics, the midwife question will solve itself. With an enlightened knowledge of the importance of obstetrical art, its high ideals, the midwife will disappear, she will have become intolerable and impossible." [1911-B; DeLeeMD]

~§ 1975 “A final underlying issue which contributed to the opposition to the midwife was the remaining 19th century bias of the medical profession, particularly obstetrics and gynecology, against women.

The nature of this bias, a contempt for women’s intelligence and physical stamina has been well-documented by Ehrenreich and English (1973), Complaints and Disorders. The vicious tone of the physicians’ articles on "the midwife problem" surely reflect this general contempt for women.

This distortion of facts, exemplified in previous quotations, demonstrates that at least the most vocal opponents of the midwife were unable to evaluate her practice objectively. As long as obstetricians sought to gain the esteem of the "medical men", they could not tolerate competition by the midwife." [Neal DeVitt, MD; 1975]

Unfortunately, it was childbearing mothers and their babies who paid the price for this campaign to deconstruct the reputation of normal birth, criminalize midwives, destroy midwifery training programs, and erase all traces of traditional (non-medicalized/physiologically-based) maternity care.

~ ¨ 1926 When the Massachusetts Supreme Court (Hanna Porn v. Commonwealth) declared midwifery to be an illegal practice of medicine in 1907, the state’s maternal mortality was 4.7 per 1000 live birth. By 1913 it had risen to 5.6 and by 1920 it was up to 7.4 [Woodbury, 1926]

~© 1917  "Of the babies attended by midwives, 25.1 per 1000 ... died before the age of one month; of those attended by physicians, 38.2 per 1000 .... died before the age of one month; and of those delivered in hospitals, 57.3 per 1000 died before the age of one month.

Restated in ratios per 1000 the numbers are:

57 for physicians providing hospital-based care

38 for physicians providing home-based care

25 for midwives providing home-based care

Testimony on the efficacy of midwifery care was presented in 1931 to the White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care: Reed (1932) concluded:

~ © 1932 “...that untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course." (italicized emphasis in original copy)

However, these objective statistics made no difference to the medical profession as their campaign against midwifery went on unabated decade after decade after decade. For example, the 1932 White House report documented the safety physiologically-based care associated with midwifery care in the “early part of this century” as did this report by Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after analyzing the work of the Frontier Nurses’ midwifery service in rural Kentucky made the following statement on May 9, 1932:

~ © 1932  “The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life."

In stark contrast to this is a 1975 quote in the New York Times Magazine which erroneously characterizes physicians as saving mothers from the “dangers” of midwifery care by forcing midwives out to the “childbirth business

~ ¨ 1975"In the United States ... in the early part of this century, the medical establishment forced midwives -- who were then largely old-fashioned untrained "grannies" -- out of the childbirth business. Maternal and infant mortality was appallingly high in those days...

 

~ “As the developing specialty of obstetrics attacked the problem, women were persuaded to have their babies in hospitals, and to be delivered by physicians.... Today it is rare for a women to die in childbirth and infant mortality is (low)..." [Steinmann, 1975]

It should be noted that the article begins by making a false association between the care of midwives and the high rate of maternal mortality at the turn of the century and ends by making another false association, this time between the historical elimination of midwifery by the organized medicine and the modern-day record of maternal safety.

The following four quotes are chronological and span eight decades (from 1915 to 1997). What is remarkable is how redundant they are. If the dates were removed, one could not tell the difference between obstetricians speaking in the first decade of the century and those speaking in the last (or the first decade of the 21st century). 

~ ¨ 1915 "The midwife is a relic of barbarism. In civilized countries the midwife is wrong, has always been wrong. The greatest bar to human progress has been compromise, and the midwife demands a compromise between right and wrong. All admit that the midwife is wrong." [1915-C; DeLeeMD.p. 114]  (emphasis added)

A letter dated August 1, 1977 by the Chief of Obstetrics of a major teaching hospital on the West Coast arguing against a bill to license and regulate non-nurse midwives:

 ~ ¨ 1977 "If we want an increase in cerebral palsy, mental retardation, extended hospitalizations for mothers undergoing infections, fistulas, hemorrhages, and other severe and disabling results of neglected childbirth, only then could one endorse bill AB 1896." Heinrichs, MD., Ph.D., August 1, 1977, Stanford University Medical Center.

An obstetrician practicing in a state with licensed direct-entry (i.e.. non-nurse) midwives in response to a question about midwifery:

 ~ ¨ 1997 “In my opinion issuing a license to a (non-nurse) midwife is giving away a license to kill.   ...  I think licensing this activity in the name of competition is wrong. In the name of quality of care it’s wrong. In fact, it’s just plain wrong” [email correspondence 08:38am 1/17/97 dk:ob-gyn-l@obgyn.net] (emphasis added)

The strategy by organized medicine to solve the “midwife problem” by crafting laws that midwives could not comply with (i.e.. first, catch your rabbit!) is still alive and well in the 21^st century. The California Medical Association authored and insisted on the physician supervisory clause of 1993 licensed midwifery practice act. The CMA assured Senator Killea that they (the CMA) would see to it that physicians provided the mandated supervision – a promise they couldn’t and didn’t keep. After the passage of the LMPA, California obstetricians and malpractice carriers closed ranks and together have categorically refuse to provide (or permit) the mandated supervision for the entire decade since the midwifery licensing law was passed. This leaves licensed midwives in California in 2003 no safer from politically-based prosecutions than the midwives of the 1911.  

The 26.8% of childbearing women in California who give birth last year by Cesarean Section are likewise still being exposed to unnecessary and unnatural dangers of interventionist obstetrics that turns a blind eye to the increased safety, lower CS rate and improved satisfaction of physiologically - based maternity care.  

Deaths per 100,000 women

Cesarean Section:	31	ratio of 1: 3,225
Breast cancer	26	ratio of 1: 3,846
Most *dangerous occupation	22	ratio of 1: 4,545
Auto accidents	20	ratio of 1: 5,000
Vaginal birth	6	ratio of 1: 16,666

Part 3 ~  Midwifery – the Bell that Can’t be Un-rung

One Minute Review of Historical Data:

~©1911 "The practice of midwifery dates back to the beginning of human life in this world. At this supreme moment of motherhood it is probable that some assistance has always been required and given. Its history runs parallel with the history of the people, and its functions antedate any record we have of medicine as an applied process.

 

To deny its right to exist as a calling is to take issue with the eternal verities of life. The only points upon which we may argue are the training required for its safe and lawful practice, and the essential fitness of those who follow this calling requisite for the safeguarding of the mother and child." [1911-G; Dr. Josephine Baker, MD; p. 232]

 

~© 1915  “The essential difference between a midwife and a physician is that (physicians) are free to hasten delivery by means of forceps, version, etc. This, in my experience, results in more serious consequences than any shortcomings of midwives.

 

...Time is an element of first importance in labor, and the midwife is more inclined to give this than is the average ... physician. ... The present wave of operative interference is disastrous. ... The situation would not be improved by turning (the clients of midwives) into the hands of such medical men....”. Dr. P.W. van Peyma, Buffalo, NY, who had 40 years of experience working with midwives and was a 25 years member of the Board of Examiners in Midwifery

 

~© 1917  These figures certainly refute the charge of high mortality among the infants whose mothers are attended by midwives, and instead present the unexpected problem of explaining the fact that the maternal and infant mortality for the cases attended by midwives is lower than those attended by physicians and hospitals." [1917-B, Levy,MD; p. 44

 

~©1924 “..... the stationary or increasing mortality in this country associated with childbirth and the newborn is not the result of midwifery practice, and that, therefore, their elimination will not reduce these mortality rates", [1924-A; Dr. Rucker, MD Rebuttal by Dr. Levy, p. 822] 

~© 1925“The practice of midwifery is as old as the human race. Its history runs parallel with the history of the people and its functions antedate any record we have of medicine as an applied science. Midwives, as a class, were recognized in history from early Egyptian times. The practice of midwifery is closely bound by many ties to social customs…." [1925-A; Dr. Hardin, MD p. 347]

 

~©1932 “...that untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course." (original emphasis) White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care: Dr Reed (1932

 

~© 1932  "The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life."

 

~© 1937  "We have had a small but convincing demonstration by the Frontier Nursing Service of Kentucky of what the well-trained midwife can do in America. .... The midwives travel from case to case on horseback through the isolated mountainous regions of the State. There is a hospital at a central point, with a well-trained obstetrician in charge, and the very complicated cases are transferred to it for delivery". [1937-A]^136

 

"In their first report they stated that they have delivered over 1000 women with only two deaths -- one from heart disease, the other from kidney disease. During 1931 there were 400 deliveries with no deaths. Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after analyzing the work of the Frontier Nurses’ midwifery service in rural Kentucky, made the following statement on May 9, 1932:

 

~© 1937  “What are the advantages of such a system? It makes it economically possible for each woman to obtain expert delivery care, because expert midwife is less expensive than an expert obstetrician. Midwives have small practices and time to wait; they are expected to wait; this what they are paid for and there they are in no hurry to terminate labor by ill-advised operative haste." [1937-A]

~© 1971  A more modern-day example of this occurred as a result of a pilot nurse-midwife program established at Madera County Hospital (California) from July 1960 to June 1963 [Levy, et al, 1971]. The program served mainly poor agricultural workers. During the three year program, prenatal care increased, and prematurity and neonatal mortality rate decreased at the county hospital. After it was discontinued by the California Medical Association, the neonatal mortality rate increased even among those women who had received no prenatal care, which suggests that the intrapartum care delivered by nurse-midwifes may have been far more skillful that delivered by physicians. Prenatal care decreased while prematurity rose from 6.6 to 9.8% and neonatal mortality rose from 10.3 to 32.1 per 1,000 live births. It is concluded that the discontinuation of the nurse-midwives' services was the major factor in these changes. [Levy, et al, 1971]

Since the early 1940s, our maternal mortality statistics have improved dramatically, due primarily to an improved standard of living and also to the development during the Second World War of antibiotics, cross-matching for blood transfusions and safer anesthetics and surgical techniques. This meant that many of the complications caused by obstetrical intervention could be successfully treated. But our perinatal death rate (up to 28 days after birth) in the United States is still at the bottom of the pile -- 23rd out of 25. Our operative delivery rate, -- sky-rocketing cesarean sections rate -- is the 2nd highest in the world. Again, the US is at the bottom -- 23rd out of 25 countries. On average, one out of every five mothers giving birth in hospitals and cared for by obstetrical services finds herself having major abdominal surgery. The maternal mortality rate for Cesarean section is 2 to 6 times what it is for spontaneous vaginal birth.

~©1975 “...in the US, physicians had little contact with midwives and never learned their useful traditions, among them, patience with nature.” [Dr. Neal DeVitt, MD, 1975]

 

~© 1988  “...there is evidence that a strong independent midwifery profession is an important counterbalance to the obstetrical profession in preventing excessive interventions in the normal birth process." [WHO, Wagner, MD; 1988]

 

~© 1988  “Midwifery provides a balance between family and (the) medical perspective on birth. To negotiate and balance the different meanings and perspective of birth within the health care system, it is essential for midwives to have a legitimate and powerful role within the system. Midwifery should be powerful enough to influence both the nature and the delivery of services. This, I believe, would greatly enhance maternity care, which ultimately is the crux of the matter..." [Page, SM, Director of Midwifery, Oxfordshire, England, 1988]

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Kate Bowland, CNM, midwife in the 1976 "Bowland Decision" by the California Supreme Court that declared traditional midwifery to be an illegal practice of medicine. This ruling was made moot by passage of the 2000 amendment to the California Midwifery Practice Act of 1993

Time to eliminate the prejudices rather than the midwives...

Having closely examined the classical ‘Midwife Problem’ and the organized campaign to eliminate traditional forms of independent midwifery, we are called upon to face disturbing facts -- the elimination of midwives was never justified on the grounds of maternal-infant safety or the public good. It was and is an injustice that seeks remedial action. The contemporary problem is this to eliminate the prejudices rather than the midwives.

Ultimately, a maternity care system is judged on its results -- the number of mothers and babies who graduate from its ministration as healthy (or healthier) than when they started. We can no longer afford to let our prejudices get in the way of the plain facts -- governments that look to midwifery care as the standard for normal births have statistically improved outcomes. This cost-effective and efficacious form of maternity care serves the social and emotional needs of healthy childbearing families far better than our expensive and inflexible high-tech model. Coupled with these social and emotional needs are the restraints of modern-day economic realities, and making reform all the more imperative. When more than 50% of all hospital admission for persons under 65 years of age (including both men and children patients) are for childbirth, we must come to terms with the economic impact of the ‘childbirth business’.

The missing link is respect by the medical community for what it might learn from midwives. In the rush to "sanitize" contemporary midwifery with hospital-based, medicalized training programs and dependent licensure under physician supervision, obstetricians and others are acting out the same prejudice used against midwives during the early 1900s. It is a prejudice that erroneously assumes that we midwives of whatever background are uneducated, untrained, unskilled and undesirable and must have our intuitive knowledge and experiential-based skills excised like a malignant disease requiring strong medicines and radical surgery.

~© 1937  "That Socrates' mother was a midwife bears testimony to the honorable nature of such a profession at a time when civilization in one of its highest forms was at its summit." [1911-G; BakerMD, p. 232

One of the current criticisms of traditional or non-nurse midwives is their lack of formal midwifery school training and in many jurisdictions, the absence of licensing for direct-entry midwives. However, it is important to remember that a central strategy of this medical campaign to eliminate midwives was to block both the training and licensing of midwives. The result is that formal education in traditional (non-nurse) midwifery has not been available for 60 years and so instead of a modest number of formally educated and certified midwives, we have a larger number of ‘lay’ midwives which, unfortunately, includes a small number who are inadequately trained and who occasionally bring harm to the mothers or babies they serve. However, physicians are not blameless. Not only can obstetrical care bring occasional harm but the stiff-armed response of the obstetrical community continues to exacerbate the problem by preventing the establishment of training programs for student midwives, licensing for new midwives and interactive collaborative relationship between practicing midwives and physicians.

"There is no alibi for not knowing what is known"
J. Rovinsky, MD -- a quote from the foreword of Davis Obstetrics:

 Midwives are suggesting, in the strongest of terms, that an exchange of expertise is in order. It is as much the responsibility of physicians to be familiar with the time-honored philosophy, principles and skills of midwifery as it is the duty of midwives to know the principles of anatomy and asepsis. Midwives are in agreement that modern obstetrics has much to teach and much to contribute to the wellbeing of the families it serves. As midwives we have already availed ourselves of both formal and informal study of obstetrical science. Likewise, the honorable but unassuming traditions midwifery -- the art of being "with women" -- the quietness of spirit, the patience with nature, the intimacy skills which serve childbearing families so well are also of great value to the bio-medical sciences. We believe that physicians cannot begin to examine their prejudices without specific information on the nature of these principles and the opportunity to build personal and professional relationships with practicing midwives.

The Late Dr. Galba Araujo, formally professor of obstetrics from Brazil, in an article urging an "articulated model of midwifery" into contemporary obstetrics stated:

"We have learned much from the traditional (midwife) and respect is mutual between our parallel groups. We have learned to teach our (obstetrical) students less invasive delivery and above all, to use the vertical position for the mother. Perhaps this is the most valuable lesson among the many we have learned."

In spite of the fears of many within the obstetrical community, midwives do not represent a feminist conspiracy to eliminate the obstetrician. Quite the obverse -- midwives seek to augment, supplement and complement the contemporary medical model of care. The jewel in the crown of independent midwifery is that it is not intrinsically in conflict with the true purpose and glory of obstetrical care -- the compassionate correction of dysfunctional states and the treatment of pathological ones. The immutable standard of maternity care is the same the world over and through out history, it is the same in every language -- the goal is and will remain the practical well-being of the mothers and babies it services... Here on the brink of the 21st century, the first duty of maternity caregivers of every educational and experiential background must be to bring about a cooperative and complimentary system that truly functions in the best interest of childbearing families.

The time to eliminate prejudice is upon us.

This philosophy of reconciliation is perhaps best described in a little-known story told about Eleanor Roosevelt during the years that she was mother of young children as well as First Lady of the land. When asked what she put first in her life, her husband (who was President of the United States), or their children, she replied that "together with my husband, we put the children first". I have always appreciated that story as portraying the ideal relationship between physicians and midwives -- that together we put the practical well-being of the mother and baby first.

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