Transaction of the American Association
for the Study
Elimination of the Midwife"
|Feb 2000||International Journal of Domiciliary Midwifery|
The following excerpts are taken from verbatim transcripts of the Transaction of the American Association for the Study and Prevention of Infant Mortality They chronicle a well-organized and well-financed effort to eliminate "The Midwife Problem". These records document the specific reasons (desire to expand access to "clinical material" to up-grade obstetricial training of physicians), the goals (elimination of competition) and tactics (fight against licensing and do not permit midwifery training schools to be established, restrict certified midwives to subservient nursing roles with mandated supervision, censor midwife-friendly physicians and criminalize uncertified midwives). These are still the bread and butter of the opposition now implemented in anti-midwife and anti-homebirth legislation and discriminatory policies of state medical and nursing boards.
Historical Bulletin #3-
"I am, therefore, unalterably and uncompromisingly opposed to any plan which seeks to give her a permanent place"I am exactly in agreement with Dr. E.P. Davis, that she is a "menace to the health of the community, an unnecessary evil and a nuisance", and I am, therefore, unalterably and uncompromisingly opposed to any plan which seeks to give her a permanent place in the practice of medicine. In no other branch of medicine do we permit ignorant, non-medical individuals to give counsel and assistance in medical matters. Midwifery is the most poorly done of all medical work, not alone because some 50 percent of all labors are in the hands of midwives, but largely because of the low standards of midwifery existent among physicians and the laity alike.
"The argument that large numbers of physicians do equally as poor obstetrics as the midwives, is entirely beside the question. We are quite ready to admit this but..."And these standards cannot be raised so long as 50 percent of the cases are in the hands of individuals with as poor preliminary education and as little medical training as have the midwives. The argument that large numbers of physicians do equally as poor obstetrics as the midwives, is entirely beside the question. We are quite ready to admit this, but to claim that for this reason we must retain the midwife, if we retain the physician, is absurd. Legally the midwife has as yet practically no status, and even if she had, there can be no reason why she should not be the subject to the same laws and requirements as those governing all other individuals practicing medicine. the fact is, as we shall attempt to point out, we can get along very nicely with the midwife, whereas all are agreed that the physician is indispensable. It thus seems that the sensible thing to do is to train the physician until he is capable of doing good obstetrics and then make it financially possible for him to do it by eliminating the midwife and giving him such other support as may be necessary.
" I am opposed to educating and licensing midwives..."p.223 I am opposed to educating and licensing midwives to practice obstetrics in this country for several reasons. First, because I believe it unnecessary, since I am convinced that a plan can be evolved and practically applied which will give every childbearing woman in the country competent medical attendants. and second, because I do not believe it possible to train women of the type of even the best of the midwives to practice satisfactorily.
"The function of the physician in midwifery cases is...to prepare the mother for, and teach her the importance of nursing her baby..."p.224 The practice of obstetrics carries with it much more than the standing by while the natural forces of labor complete the act as best they can. Obstetrics is an important branch of medicine and to practice it safely and successfully implies a knowledge of general medicine, as well as a knowledge and appreciation of physiology and pathology -- the normal and the abnormal -- of the childbearing process. 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.
"... pertinent objection to the midwife is that she has charge of 50 percent of all the obstetrical material...."Another very pertinent objection to the midwife is that she has charge of 50 percent of all the obstetrical material [clinical material or teaching cases] of the country, without contributing anything to our knowledge of the subject. As we shall point out, a large percentage of the cases are indispensable to the proper training of physicians and nurses in this important branch of medicine. The whole country is indebted to Dr. J Whitridge Williams [original author of Williams Obstetrics] for his studies on "Medical Education and the Midwife Problem in the United States." He has done a great and lasting service in laying bare the facts in regard to the teaching and practice of obstetrics in the country. On the other hand, Dr. Jacobi in his inaugural address, at the meeting of the American medical Association at Atlantic City in June of this year (1911) has taken in my opinion a decidedly backward step as regards both the teaching and practice of obstetrics. His recommendation that 200 schools for midwives be established in the US is an impractical as it would be impossible to accomplish. According to Dr. Williams, but a single medical school in the country has adequate facilities for teaching obstetrics properly to medical students.
".... can hope to compete with the German medical schools.."So much is needed before we can hope to give to the students gradating from our medical schools adequate training in obstetrics and before we can hope to compete with the German medical schools. If then, in addition, an attempt be made to establish the 200 schools recommended by Jacobi, using the university schools also to train midwives as in Germany, some idea may be gained of the utter foolishness of such a recommendation.
"....depriving (physicians) of clinical material for their training, in order to provide trained midwives..."p.225 It is at present impossible to secure cases sufficient for the proper training of physicians in obstetrics, since 75 percent of the material [i.e.. childbearing mothers] otherwise available for clinical purposes is utilized in providing a livelihood for midwives. If schools for midwives were established in al the larger cities of the country a large number of additional cases would become necessary for training the midwives and we should soon find ourselves in the anomalous position of favoring the elimination of the physicians from the practice of obstetrics, by still further depriving them of clinical material for their training, in order to provide trained midwives to supplant them. If, more over, the money which would be necessary for the establishment and maintaining 200 schools for midwives, together with what would be necessary to supervise the midwives properly in their practice afterwards, were used to pay physicians and nurses care for the midwife cases, sufficient money would be available, to say nothing of the 5 million dollars which it is estimated in collected annually by midwives in this country and which should be paid to physicians and nurses for doing the work properly.
"We are totally indifferent as to what becomes of her..."The question in my mind is not "what shall we do with the midwife?" We are totally indifferent as to what becomes of her, as compared with the very vitally important question of how we shall provide competent medical services for the hundreds of thousands of the very best of our women while they are fulfilling the sacred obligation of maternity [interesting to note that women as midwives as dismissed with "total indifference" while women as clinical material are ennobled with "sacred obligations of maternity].
" ... [medical] students deliver no cases in a hospital under supervision ...... receive little even in the way of demonstrations on women in labor and are sent .... to deliver, at most, but a half dozen [domiciliary]cases..."p.226 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 and motives but the deficiency in obstetrical institutions and in obstetrical material [^] for teaching purposes has been even greater. It is today absolutely impossible to provide material [^] enough to give medical students anything more than the merest smattering in practical obstetrics. So far as I have been able to learn, in all but a few medical schools, the students deliver no cases in a hospital under supervision, receive but little even in the way of demonstrations on women in labor and students deliver no cases in a hospital under supervision, receive little even in the way of demonstrations on women in labor and are set into out-patient departments to deliver, at most, but a half dozen cases. 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 to a great nation, which in other branches of medicine holds high rank. 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.
"She should ... not be given a license but should be given a certificate, to be renewed from time to time or canceled as deemed advisable..."
"No attempt should be made to establish schools for midwives..."p.227 I believe that the midwife should be eliminated as rapidly as possible, but I do not believe that this can be accomplished at once nor perhaps very rapidly. Legislation will not eliminate the midwife unless hand and hand with such legislative provision is made to take her place. While a substitute is being provided she must be supervised in her work. She should, however, not be given a license but should be given a certificate, to be renewed from time to time or canceled as deemed advisable under the circumstances. Licensing her will not add to her knowledge, and will not make her more efficient but will place upon the state permanent responsibility for her work. No attempt should be made to establish school for midwives, since, in my opinion, they are to be endured in ever-decreasing numbers while substitutes are being created to displace them.
"...Physicians have been called upon to do much more than their share..."p.228 ....Physicians have been called upon to do much more than their share. there is not the slightest reason why the physician should give his professional services without compensation to the dependent and sick poor than that of any other citizen. The fact that he is especially fitted to so serve them does not in any wise alter the situation. The poor when ill are the States charges, just as much as when they must be fed, clothed and sheltered, and the State should administer to the needs in one case just as much as in the other. Until physicians are justly compensated for their services to the poor they will not receive adequate medical attention. ....Public charities of all kinds should be well organized, thoroughly supervised, and all the workers should be justly compensated.
"The placing of the burden of medical service to the poor upon physicians..."The placing of the burden of medical service to the poor upon physicians, without compensation, has led them to see in return excessive fees from those who can pay, with the result that much harm has been done to the cause of medicine. The practice of medicine has been thereby converted into a trade, and commercialism has destroyed much of its higher and finer side, and has done untold harm in the attitude with the public should have towards the physician and the schools which educate them. And for this the leaders of the profession, the teachers of medicine, have been largely responsible.
"...Medical education and medical services to the poor should go hand and hand..."p.229 In medical charities economy and efficiency are all important and can best be secured when such charities are utilized for teaching purposes. Medical education and medical services to the poor should go hand and hand, since patients in teaching institutions receive the best possible attention and at the least cost to the State. ....It is generally not appreciated that medical schools should be first of all educational institutions rather than medical institutions; than they should be... public service organizations and exist for the public good, as do other educational institutions, and the teacher of medicine should be an educator in the highest sense of the term and should stand in the closest relationship to all the problems of medical education, medical practice, eugenics  and social service. He should spend his life .... as a public servant, and use his calling and ..opportunities that go with it, not to enrich himself at the expense of the profession, but to serve his generation in all that pertains to the public good. For all these reason medical schools should be liberally supported by the State as in Germany, where medical education and service have reached their greatest development.
"...The physician exists ... for the benefit of the patient, and not the patient for the benefit of the physician..."p.230 .....---the size of the family, the income and cost of living, the actual legitimate earning capacity of the family... If the income, whatever it might be, is entirely needed for the necessities of life, it ought not to be used to pay physicians fees. Such individuals cannot ... be looked upon as of any legitimate financial value to the physician whom their [charity] care by hospitals and dispensaries should give no cause for offense. the manifest and professed purpose of the science and art of medicine is the prevention and cure of disease. The physician exists ... for the benefit of the patient, and not the patient for the benefit of the physician; and the solution of this matter will not be reached until this fact is fully appreciated, and until it governs our attitude toward providing medical service for the dependent poor. Any system ... which does not provide the most economical service consistent with essential efficiency is wrong. On the other hand, physicians should not be criticized for not giving medical service to such patients but on the contrary, should be paid for it, and this applies with equal force to nurses and social workers.
"... elimination of the midwife is to be brought about in time through the establishment of obstetric charities ..."p.231 From what has been said it will appear that the elimination of the midwife is to be brought about in time through the establishment of obstetric charities consisting of maternity hospital and maternity dispensaries, with all that goes with them in the form of social services, visiting nurses, prenatal work, etc. the hospital is to care for all who, for one reason or another, cannot secure proper attention at home and the dispensary for those are delivered at home. The majority of women will always be cared for at home and it is desirable that they should be when conditions permit it. A mother with a number of children cannot usually leave them to the advantage, and while it is true that physically she cannot and should not care for them, her presence in the home is necessary to order and discipline. Then too, the cost of caring for patients in hospital is much greater than in their own homes.
"...The majority of women will always be cared for at home and it is desirable that they should be..." "... the cost of caring for patients in hospitals is much greater than in their own homes."
"... each [medical]student should be required to deliver personally not less than fifty cases under careful supervision, and should also be taught to do upon the living subject all the obstetrical operations which the granting of his diploma gives him license to perform..."p.232 My own feeling is that before going into private practice each [medical]student should be required to deliver personally not less than fifty cases under careful supervision, and should also be taught to do upon the living subject [code for woman as object] all the obstetrical operations which the granting of his diploma gives him license to perform; as I hold that is little less than criminal to permit practitioners of medicine to jeopardize the life and health of human beings by performing upon them operations which they have not done, and perhaps have never seen performed in their student days. The average practitioner who gains his experience in obstetric operating solely upon his own responsibility rarely ever learns to do it safely, and therefore, always remains a menace to his patients, and should he eventually become an accomplished operator, his knowledge has been gained at the cost of much invalidism and of a number of deaths. .......
" If the midwife cases .... were used for teaching purposes ....sufficient clinical material [!] would be available to give every graduate in medicine...."The public should learn that it is the duty of every citizen, if for no other reason than that of the safety of his own family, to insist that students of medicine be not only supplied with clinical material, but they be required to utilize it in acquiring the knowledge which is indispensable to efficiency in the practice of obstetrics. If the midwife cases .... were used for teaching purposes, not only would the patients themselves receive excellent care, but sufficient clinical material [!] would be available to give every graduate in medicine such obstetrical training as would make him a safe and efficient practitioner. p.233 In New York City, according to Dr. Baker, 51,996 births, or 40 percent of the total number in 1911, were in the hands of some 1,300 midwives. In Philadelphia ... the estimated number of birth was 44,000 ....21 percent or 8,450, were delivered by 194 midwives. The number of registered midwives in Baltimore is 162. There were 15,422 reported birth in Pittsburgh in 1911 of which 4,864 or 31 percent were delivered by 150 midwives. Of 12,839 birth reported in Cleveland .....40 percent were in the hands of 266 midwives. . p.234 On the basis of the number of students graduating annually (1911-1912) the combined medical schools .... it is interesting to see to what extent the midwife cases in these cities could be handled by students alone. In the data given it would appear that in some instances not all of the cases credited to undergraduate students were actually delivered by them, since many of the deliveries were most probably demonstration cases, observed collectively by a number of students while the actual delivery was being conducted by one of their number under supervision. In this study it is estimated that if midwives did not exist, at least 25 percent of the cases now under their care could afford to and would employ physician 1. Boston Number of students 190; cases delivered by students in out-patient [home] births 3500 (19%); midwife cases, 1980 (11%). Cases credited to each student 18, and 10 additional to handle the midwife cases or a total of 28 cases per student. 2. Philadelphia Number of students 437; cases delivered by students in out-patient [home] births 2,566; midwife cases 6,338 (11%). Cases credited to each student 6, and 15 additional to handle the midwife cases or a total of 21 cases per student 3. Baltimore Number of students 334; cases delivered by students in the hospital and dispensary [home births] 1746; midwife cases 6,375. Cases credited to each student 5, and 19 additional to handle the midwife cases or a total of 24 cases per student 4. Pittsburgh Number of students 66; cases delivered by students in out-patient [home] births 264; midwife cases 3,648. Cases credited to each student 4, and 55 additional to handle the midwife cases or a total of 59 cases per student 5. Cleveland Number of students 66; cases delivered by students in out-patient [home] births 605; midwife cases 3,845. Cases credited to each student 9, and 58 additional to handle the midwife cases or a total of 67 cases per student 6. Chicago Number of students 608; cases delivered by students in out-patient [home] births 1,927; midwife cases 21,540. Cases credited to each student 3, and 35 additional to handle the midwife cases or a total of 38 cases per student 7. New York Number of students 325; cases delivered by students in out-patient [home] births 3,780; midwife cases 38,997. Cases credited to each student 12, and 120 additional to handle the midwife cases, or a total of 132 cases per student. If the students delivered 50 cases each of a total of 16,250, there would still remain 26,527, so that in NYC at least it would seem that the midwives must do a large part of the work for some time to come unless the City or State does a considerable part of the work through dispensaries, employing physicians and nurses on salaries. p.235 At the same time this would not be so much of an undertaking as it at first appears, since fully 50 percent of the 38,997 midwife cases could pay to the dispensaries as they now pay to midwives -- $10 each---and the remainder could pay at least $5 each, the minimum midwife fee in NYC. If the midwives were eliminated in NYC, all their cases could be handled through maternity dispensaries for an additional expenditure of not over $100,000 a year, provided such dispensaries received as much in fees as the midwives now do.
" ... obstetric charities, such as I have attempted to describe, and the education of the people will in time make the midwife unnecessary and her elimination inevitable."p.237 The work in Pittsburgh is young, but the outlook is most promising, and we feel that we have in the combination of hospital and dispensary [for extending domiciliary services] both teaching institutions, the solutions of the midwife problem. And what can be done in Pittsburgh can be done in easily other large city in the country. The creation of obstetric charities, such as I have attempted to describe, and the education of the people will in time make the midwife unnecessary and her elimination inevitable.