Excerpts from a paper presented to the Committee on Midwifery
"Progress Towards Ideal
Obstetrics"
Pages 114-123 Chicago; 1915
by Dr. Joseph DeLee, MD ,
ABSTRACT:
Dr. DeLee’s name is one of the most well-known in the field of obstetrics. He defined "professionalism" for many decades by his theory that childbirth was itself a pathologic state, about as "normal" for the mother as "falling on a pitch fork". He insisted that the baby was inevitably damaged by being used as a "battering ram" against the mother’s "iron" perineum. These philosophies elevated the routine use of episiotomy and forceps as a crucial adjunct to "good" obstetrics and are still influential today. He also invented obstetrical forceps that bear his name and the DeLee mucus trap, used the world around to prevent meconium aspiration in newborns.
Dr. DeLee and Dr. Williams (see IJDM bulletin #1) were contemporaries. They were the most prominent and highly respected obstetrical professors of their era and both authored major textbooks on obstetrics. They were also professional rivals and person enemies who frequently tried to out do each other, especially in their anti-midwife rhetoric. Dr. DeLee related to most problems within his profession as another opportunity to vilify the midwife and frequently displaced blame for the short-coming of his own profession on midwives (scape-goating).
In this paper, Dr. DeLee addresses the controversy surrounding professional education for midwives -- something he was "heart and soul" against. Like Dr. Williams, he acknowledged the deplorable circumstances of obstetrical education and admitted that more mothers died at the hands of physicians than midwives. However, he then used these facts, along with his personal prejudices and his own professional agenda, to come to a totally illogical and morally-repugnant conclusion.
First, he ignored the fundamental questions of responsibility and accountability for the harm being done routinely by the substandard or aberrant care of physicians. Second, he exploits the increased maternal and infant death rate among physician-attended births as proof that the medical profession should, as a matter of policy, withhold professional education from midwives.
He admitted that formal training for midwives would improve their skills and increase the good outcomes enjoyed by their patients. He asserted that the advantage to mothers cared for by professionally trained midwives (40% of the general population) would deny important educational opportunity to medical students and delay the general advancement of the obstetricial profession. According to him, this would have been to the detriment of the 60% of mothers who choose physician careproviders. He actually says that he is willing to have poor, ignorant or immigrant mothers die in return for achieving a "greater" good to well-to-do, educated, and American women. In his own words: "It is therefore, worth while to sacrifice everything, including human life, to accomplish the ideal".
However Dr. DeLee’s "ideal obstetrics" was then, and remains today, an unproven theory. Obstetrics is a surgical branch of medicine predicated on intervening with the normal flow of events and has always been an experimental form of medicine. In the face of desperate circumstances such as obstructed labors or maternal hemorrhage, doing something was obviously better than doing nothing. Only the rare obstetrical problem made these heroic but "experimental" (scientifically untested) interventions such as anesthesia, episiotomy, forceps or cesarean surgery appropriate and, one hoped, life-saving.
But for healthy childbearing women experiencing normal pregnancies, no such justification applies. No body of scientific knowledge has ever supported the general use prophylactic obstetrical practices which none-the-less, quickly became the routine all across America. No research was ever undertaken which contrasted the care of midwives with that of physicians. No scientific studies have ever demonstrated the superiority of obstetrical interference over the non-interventive midwifery model of maternity care.
Scientists never researched the impact or safety of routinely hospitalizing healthy mothers. No outcome studies that examined the interventions of "modern" obstetrics have scientifically validated them for routine use on healthy mothers. These include pubic shaving, putting laboring mothers to bed, keeping them NPO (nothing by mouth), restricting their physical movements (and their visitors), time limits for different stages of labor, use of electronic fetal monitoring, the lithotomy position for delivery and all the other limitations and artificialities imposed by obstetrical protocol.
We do know from multiple reliable sources of maternal-infant statistics -- both historically and in contemporary times, in the US and in Europe -- that infection rates, ratio of operative deliveries, anesthetic accidents, increased maternal hemorrhage, prematurity, stillbirths, number and severity of birth injuries and many other complications are associated with hospital-based, physician-attended childbirth. This is as true today as it was in the early part of the century.
Excerpts
Progress Toward Ideal Obstetrics
By Dr. Joseph DeLee, MD
p. 114
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...
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.
Even after midwifery was practiced by some of the most brilliant men in the profession, such practice was held opprobrious and degraded. Less than 100 years age, in 1825, the great English accoucheur Ramsbotham complained of the low esteem in which he was held by his brother surgeons. He was denied admittance to the Royal College and his colleagues would dare not be seen talking to him on the street!
p.115
Obstetrics is held in disdain by the profession and the public.. The public reason correctly. If an uneducated women of the lowest class may practice obstetrics, is instructed by the doctors and licensed by the State, (attendance at childbirth) certainly must require very little knowledge and skill ---surely it cannot belong the science and art of medicine.
Dr. Ziegler of Pittsburgh, says: "Both the teaching and practice of obstetrics are generally regarded as the poorest of all the clinical branches of medicine.. There must be a reason for this. The lay public will continue to regard with indifference all pleas for the improvement in the teaching of ...obstetrics so long as more than 50% of confinements are in the hands of ignoring, non-medical persons, who, as a class, are regarded as capable of doing the work satisfactorily, even by physicians, among whom are certain well-known professors. [a thinly-veiled slam against Dr. DeLee’s arch rival -- Dr. Williams]
Do ophthalmologists favor a school for the instruction of optometrists...? Why not train the chiropractor and Christian Scientists also? p. 115
p. 116
Engelman says: "The parturient suffers under the old prejudice that labor is a physiologic act," and the 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.
p.117
If the profession would realize that parturition, viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention.
If the public would acknowledge the dignity of his specialty it would properly remunerate him for his services. If the specialty were as remunerative as the other departments of medicine it would attract large numbers of young men.
It is generally admitted that more women die during confinement in the hands of doctors that among midwives. (Dr.) Williams, in his remarkable and epoch-making paper, seems to have demonstrated this as the prevalent opinion. The fact that only about 40% of the women in the US employ midwives does not explain the difference. p.117
p. 118
The energy directed to the training of midwives would bring greater results if spent on doctors. This would improve the conditions of the 60% -- and the 40% would be benefited indirectly, also.
We are asked to educate the midwife as a matter of expediency, to provide a little better care of the poor, the ignorant woman or foreigner and, we are told, though I do not believe it, that 40% of the women in American must have midwives. The 60% employing doctors are well to do, or at least no paupers --- educated and Americans.
Now I hope I will not be misunderstood... I ...take second place to no man or woman in my regard for the poor, the ignorant, the foreign born childbearing mother. But I have just as high regard for the well-to-do, the educated and the American woman and I must raise my voice against a measure which, I am convinced from 25 years of deep, close observation and study, will tend to jeopardize her health and life. While we may, by educating midwives, improve the conditions of the 40%, we will delay progress in ameliorating the evil conditions under which the 60% now exist. For every life saved in the 40% we will lose many more in the 60%.
Ideas and ideals are the hardest things in the world to establish, but once established they are impossible to eradication and they raise the plane of human existence. It is herefore, worth while to sacrifice everything, including human life, to accomplish the ideal. Knowing this I am willing ... to close my eyes to what the midwives are doing (i.e. to prevent the professional education of midwives) and establish high ideals. Then all, poor and ignorant, as well as rich and educated -- the 40% as well as the 60% will enjoy the benefits of improved conditions.
In all human endeavor improvement begins at the top and slowly percolates down throughout the masses. One man runs ahead of the crowd and plants a standard, then drives the rest up to it. Search history, biblical and modern, and this fact stands out brilliantly.
p. 120
What has been done to take the midwife’s place? In the larger cities, Boston, NY, Philadelphia, Baltimore, Pittsburgh, Chicago, substitute agencies are supplanting her and what is still more hopeful, even the poor foreigner is becoming enlightened as to the value of medical attendance and is demanding it.
p 121
Since poverty is given for the cause of the perpetuation of the midwife, let us see if there be not some way to eliminate poverty at least as far as childbirth as concerned.
The free maternity hospital take away a certain number ... but growing each years. The number of beds in hospitals for women of moderate means is also increasing rapidly. The free dispensaries --- or out-clinics are now caring for a very large percentage of the cases.... I would guess that in Chicago, about 1/5 of the births are cared for by institutions of the dispensary type.
p. 122
III. It is impossible to train the midwife sufficiently to make her a safe person to attend labor cases.
After what has been said it is superfluous to dilate on this point. Obstetrics is a major science. It requires the highest kind of skill in addition to much knowledge to do even tolerable work. The high class of work and superior knowledge required of the infant welfare nurses... all throw into relief the impossibility of training the midwife for any good purpose.
But all these arguments are unnecessary and insult one’s intelligence. I have visited many European clinics and I am convinced that the reason they are so far behind ours in their obstetric technique is because of the presence of the midwife and the low ideals she establishes (for example, valuing of normal progress and eschewing the routine use of interventions such as chloroform, episiotomy and forceps).
I would refer to the paper of Drs. Emmoms and Huntington of Boston, read in Chicago four years ago. Their ideas are identical with mine. I am heart and soul opposed to any measure which is calculated to perpetuate the midwife. In educating her we assume the responsibility for her; we lower standards, we prostitute ideals, we compromise with wrong and I, for one, refuse to be particeps criminis.
p. 123
We for the lesser evil, we lose the greater good. Finally she is not a necessity.. The rural districts are already getting along very well without her. The foreign population of the cities is being taken care of better every years and as their education improves, will also learn to do without her.
My special thanks to Stanford University and the staff of Lane Library, (the medical school library) for their invaluable assistance to me in researching these topics and acquiring the necessary photocopies of this archival material for posting on the Internet. In particular I wish to express my profound gratitude the Librarians for their untiring assistance to me -- a "virtual virgin" in library science. It is solely due to Librarians that this archival material was persevered for our generation.
Transcribed by faith gibson, community midwife
copyright 1996
Permission to reproduce unchanged