International Journal of Domiciliary Midwifery
Excerpts from a paper presented
Dr. J. Whitridge Williams
original author of Williams Obstetrics
Transactions of the Second American Association
for the Study and Prevention of Infant Mortality
November 9-11, 1911
Pages 165 through 198
The Chairman of the Committee on Midwifery* invited Dr. Williams to make this presentation. His was the first paper presented at the 2nd annual meeting of this new professional association.
Dr. Williams began his presentation by describing a survey of professors of obstetrics from 120 medical schools. Forty-three professors replied, representing school in every section of the country.
Dr. Williams concluded that maternity care as provided by the physicians of his day was significantly more dangerous than that of midwives --to the great shame of doctors -- and that reform of obstetrical education was urgently needed to bring medical education in United States up to the "gold standard" as established by Germany and other European countries. However, it was agreed that there was not enough "clinical material" (teaching cases) to properly instruct the large number of medical students enrolled in 120 different medical schools. This problem was blamed on midwives, lower class women who were considered to be "wasting" all that good clinical material ever time they attended a birth. Since it was "obvious" that physicians were "necessary" while midwives were "not necessary", it was recommended that midwives be abolished to provided better training opportunities in medical schools.
The plan to eliminate the competition of midwives included free maternity care through "obstetrical charities" (mostly Rockefeller and Carnige foundation money) and free admission to teaching hospitals for lower class women who otherwise would have chosen the care of midwives. Many authors of the era insisted that "the government" should pay for this system of free care for purposes of medical teaching out of tax revenues, in recognition of the great public benefit derived from medical education. This concept eventually became our modern-day Medicare system.
Dr. Williams always refers to teaching cases as "clinical material", which in actuality referred to the warm human bodies of women who made their childbearing processes available as a teaching tool in return for "free" maternity services. Unfortunately, this cost many of them their lives, as medical interventions of the day (routine use of chloroform & forceps) were particularly dangerous. While the information provided by Dr. Williams often favored the work and greater safety of midwives, he routinely uses the adjective "ignorant" in front of the term "midwife". It should be noted that he was much less denigrating of midwives than most of the physicians of his day.
[Editors Note: *the word "midwifery", as used here, refers to normal maternity care which historically was the occupation of midwives. By the early 1900s -- a time when women did not yet have the right to vote -- the discipline of midwifery had already been appropriated by "medical men" as an expanded scope of their own medical practice. With that in mind, they spoke of "The Midwife Problem" or "Eliminating the Midwife" rather than eliminating "midwifery", per se. Many textbooks that taught the principles of maternity care to physicians still used the original term "midwifery" in their title and described a physician who provided such care as a "man-midwife" . However, the goal of the medical establishment was to take over the historical profession of midwifery, change the name to "obstetrics" and divide it up between the modern and more "scientific" professions of medicine and nursing. The ideal as described was specially trained nurses that were to be employees of the physician or hospital who would attend women during the labor, and physicians, who were to be called when birth was imminent. Physicians then collected a substantial profession fee from the family while the nurse was paid a modest hourly wage. This is still the standard arrangement for maternity care in the US. ]
Dr. J. Whitridge Williams, MD
"For many years I have regarded the general attitude toward obstetrical teaching as a very dark spot in our system of [medical] education and the majority of the replies to my questionnaire indicate that my pessimism was more than justified. Briefly stated, they indicate (a) many professors are inadequately prepared...; (b) a considerable proportion are not competent to cope with all obstetrical emergencies; (c) nearly all complain that their teaching and hospital equipment is inadequate for the proper teaching of students; and (d) a large proportion [of obstetrical professors] admit that the average practitioner is not prepared for the practice of obstetrics and does his patients as much harm, if not more, than the much-maligned midwives."
"If such conclusions are correct, I feel that ...[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." p.166
"Moreover, it is interesting to note that one professor admitted that he had never seen a woman delivered before assuming his professorship, while in 5 states they had seen less than a hundred cases, and 13 other less than five hundred. Such conditions however, are in marked contrast with those obtaining in Germany and France, where the first requirement for a professorial career is a long period of preparation in a well equipped lying-in hospital with abundant clinical material."
"In smaller medical schools, each student, on an average, has an opportunity to see only one woman deliver which is manifestly inadequate. Bigger institutions, ... have ...an average of only four cases per student."
"The actual figures show that in 25 schools each student sees 3 cases or less; in 9 schools, only 4 to 5 cases, and in 8 others, 5 or more cases; while in some of the smaller hospital this is possible only by having 4 to 6 students examine each patient, and thereby subjecting her to unjustifiable risk of infection. "
"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 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."
p. 172 Question #12: "Do you maintain an outdoor (domiciliary) service?"
"The following answers were received:
6, small without data;
16, with less than 250 (home) deliveries;
6, between 250 and 500 (home) deliveries;
5 between 500 and 1,000 (home) deliveries and
5 with 1,000 or more (home) deliveries per year."
[32 hospitals with a combined estimate of 12,000 to 20,000 home births annually]
"At first glance these figures appear much more satisfactory than those for lying-in hospitals, as they show that ten of the schools have a fair material. In order to be efficient for teaching, an out-patient service must be held in rigid discipline, be organized as an integral part of the regular obstetrical service, and conducted through the lying-in hospital. Moreover, the students should be accompanied by an assistant to demonstrate the care as well as by a trained nurse to prepare the patient properly.[i.e. public shaving].. Under such conditions, out patient material may be utilized for teaching purposes almost as satisfactorily as ward patients."
"In hospitals in which there is not co-operation between the two departments, the obstetrician is looked down by the gynecologist, and is usually afforded markedly inferior facilities for his work.
... as the number of radical operations in obstetrics is comparatively limited, the most natural method of obtaining the desired facility (i.e. ability) is by means of gynecological surgery. .... no one can be a competent obstetrician without being at the same time a trained gynecologist. I consider from the standpoint of teaching that those schools will possess a considerable advantage in which the two chairs are fused. ...if obstetrics is to occupy the position it deserves, .... every effort should be directed towards the funding and endowment of Womens Clinics in every true university medical school, more or less along the lines as in Germany".
"Several professors frankly admit that they are not prepared to perform Cesarean section.
Consider that such a condition of affairs means that the professor is merely a man midwife, who is unable to carry a complicated case of labor to its legitimate conclusion! Or imagine the effect upon a patient, ...when told that he can conduct the case satisfactorily [only] if it is ended by the unaided efforts of nature (i.e. spontaneous birth), or merely requires some slight interference, but in case radical interference is demanded he will be obliged to refer her to a gynecologist or surgeon. Think of the impression such an admission must make upon the student, who cannot be blamed for believing that obstetrics is a pursuit unworthy of broadly educated men, but suitable only for midwives." p. 174
"Such being the case, can anyone be surprised that obstetrics is looked down upon by the other departments of the medical school and is not regarded seriously by most students and practitioners".
p.178 -- Question #19 "Do you consider that the ordinary graduate from your school is competent to practice obstetrics?"
"...several designate them as fairly efficient man-midwives. Moreover, most of them admit that the gradates are not competent to conduct operative labors .... several state that they deteriorate rapidly in technique after leaving the medical school. 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, being made up of graduates from 128 colleges and universities in this country and Europe -- 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."
"In general, ...the medical schools in this country, the facilities for teaching obstetrics are far less that those afforded in medicine and surgery; while the teachers as a rule are not comparable to those in the German Universities. ...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. I do not want to imply that the American graduate, even with his faulty training, is very much worse than in other countries, as I have seen in Europe some of the most horrible obstetrical tragedies in the hands of practicing physicians of long-standing."
p. 179 Question #20 "What proportion of labor cases in your city are attended by midwives?" [By 1900, already 50% of births, on average, were physician-attended]
"The replies indicate great variation in different localities. ...in most of our large cities, in including NY and Chicago, St. Louis, and Atlanta, they conduct from 40 to 60% of all labor cases. Concerning their necessity, ...31 gave positive answers, 15 stated that they were necessary and 16 not."
Question #21 "Do you believe that more women die from puerperal infection and eclamsia in the practice of midwives or general practitioners?
"...of the 35 who answered , 17 stated [that more mother die from the care of physicians] while 13 [that more from the care of midwives] while 5 held that their death rate was about equal. ...the majority of teachers in this country consider that general practitioners lose as many and possibly more women from puerperal infection than do midwives. This is an appalling conclusion as it is generally believed that infection is the main cause of preventable deaths in the practice of the latter[i.e. midwives]."
p. 180 Question #22 "Do as many women die as a result of ignorance or ill-judged and improperly performed operations in the hands of general practitioners, as from puerperal infection in the hands of midwives?"
"of the 35 [who answered], 26 said the general practitioner. Moreover, [many report] the unnecessary deaths of large numbers of children resulting from improper operating, and the failures to recognize .. a contracted pelvis. As the argument usually advanced against the midwife is the frequency with which infection occurs in her practice, such conclusion comes as a surprising revelation.
What a showing! The generally accepted motto for the guidance of the physician is "primum non nocere;" and yet more than 3/4 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 ignorant midwife does by neglect of aseptic precautions.
[Editors Note: The scientific basis of microbiology was only demonstrated for the first time in 1881. Thus the understanding of germ theory and the role of bacteria as the causative pathogen in puerperal sepsis was only about 25 years old at this point in history. The teaching of aseptic principles in the US was limited to the professionally educated, mainly in medical and nursing schools. However, within a decade or two, this scientific understanding of sanitation, hygiene, the importance of handwashing, and the sterility of anything introduced into sterile body cavities played in the prevention of contagion became part of our general education. Since then, one did not need to be trained as a physician or nurse to appreciate and utilize "aseptic precautions".]
"If it appears necessary to reform anything, here is the opportunity. Why bother the relatively innocuous midwife, when the ignorant doctor causes many more absolutely unnecessary deaths. From the nature of things, it is impossible to do away with the doctor, but he may be educated in time; while the midwife can be abolished if necessary. Consequently, we should direct our efforts to reforming the existing practitioners and to so changing our methods of training students as to make the doctor of the future reasonably competent."
Question 23 "How do you consider that the midwife problem can best be solved?"
" .... thirty-four answers ...gave the following results: 18 advocate the regulation and education, and 14 the abolition of midwives...".
"A thoroughly competent professor in one of the large cities, in which more than 1/2 of all labors are conducted by midwives, states [that] although the smaller portion of obstetrical work is in the hands of physicians that they, nevertheless, lose from infection many more women than do the midwives. ....one of the respondents from New York City states that owing to the extension of lying-in charities, midwives now attend many less women than formerly... A similar statement comes from Cincinnati, where without stringent regulation, the number of women attended by midwives has decreased from 70% in 1880 to 30% in 1909, thus tending to indicate that prolonged residence in the country gradually overcomes the prejudice of our foreign-born population against the employment of physicians."
"...(D)ivergent arguments are advanced by those favoring the abolition of midwives. One group regards as hopeless any attempt to train them efficiently; while another holds that they may be entirely done away with by educating the laity, by extending lying-in charities and by supplying better doctors and cheaper nurses.. "
Question 24 "Can you suggest any practical method of improving the general standard of practical obstetrics outside of hospitals?"
1. Better teaching and more abundant lying-in hospital accommodations.
2. The profession and laity should be taught that obstetrics is surgery, and that its major operations are as serious as laparotomies.
3. Education of the laity concerning existing conditions and insistence that the proper place for major obstetrics (i.e. surgery) is a well-conducted hospital.
4 Regulation of obstetrical practice by the State Board of health, which should grant a provisional license ...revocable upon demonstration of incompetency or neglect.
5. Better education of practitioners. A number of respondents do not believe that the present generation [of doctors] can be materially improved.
6. Teaching both doctors and the laity that the ordinary practitioner should attend only normal cases, and should refer the abnormal ones to specially trained men connected with well-equipped hospitals.
7. Better pay for practitioners doing general obstetric work ....
8. The collection and general dissemination of accurate statistics concerning the mortality of childbirth as well as the injuries and illness which result from improper care.
9. Elevation of the importance of obstetrics in the eyes of practitioners, medical students and the laity.
10. Marked extension of obstetrical charities and well organized lying-in hospitals.
11. The gradual evolution of a better class of practitioners. A slow progress, as very little improvement can be expected within the present generation.
12. Greater development of visiting nurses for those of moderate means and the education of trained helpers to carry out their directions.
13. Differentiation of [medical] students into two classes, one of which should be educated as a man-midwife, and the other as a broadly-trained obstetrician.
"I am convinced that no fair-minded person ... can read the foregoing analysis without feelings of profound depression, or without admitting that we are facing a condition urgently in need of reform."
"The replies clearly demonstrate that most of the medical schools ... are inadequately equipped for their work and are each year turning loose upon the community hundreds of young men who are not properly prepared for the practice of obstetrics and who cause the unnecessary deaths of thousands of women and young infants, not to speak of a much larger number who are ... permanently injured by improper treatment or neglect. Moreover, the spontaneous admission by more than 3/4 of the respondents that medical men are responsible for more deaths in childbirth than the much maligned and ignorant midwife, forces to acknowledge that improvement in the status of the latter (i.e. midwives) alone will not materially aid in solving the problem."
"A priori, the replies seem to indicate that women in labor are safer in the hands of admittedly ignorant 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 (i.e. midwives) and the abolition of medical practitioners, which would be a manifest absurdity."
"The discrepancy is in part explicable by the fact that, with few exceptions, midwives recognize their inability to cope with obstetrical emergencies and therefore limit their activities to the care of apparently normal cases of labor; with the result that their patients die only from infection or conditions following procrastination or neglect in soliciting medical aid. On the other hand, the average practitioner does not recognize his own limitations, but in his ignorance feels that he is as competent to cope with abnormal conditions as his efficiently trained confrere, whose aid he solicits only after futile attempts at delivery have demonstrated his inability to complete the task. Consequently, the specialist as a rule does not see the patient until her condition has be come deplorable."
"Furthermore, I desire to go on record as stating that the average practitioner is not entirely to blame for his ignorance in obstetrical matter, as he is usually as benevolent, as intelligent and as anxious to do good work as anyone else. The fault lies primarily in poor medical schools, and in the low ideals maintained by inadequately trained professors, and in the ignorance of the long-suffering general public".
Some necessary reforms are :
a. Better and properly equipped medical schools
b. Higher requirement for the admission of students to medical schools
c. Scientifically trained professors of obstetrics with high deals
d. General elevation of the standards of obstetrics
e. Education of medical practitioners
f. Education of the general public
g. Development of lying-in charities
h. Cheaper nurses
i. Possibly the training of midwives
MEDICAL SCHOOLS: "(S)ufficient clinical material are urgently demanded.
It is highly desirable that the lying-in hospital be owned by the university or if not, that it should be in the closest possible affiliation with the power of appointment vested in the proper university board. (P)ractical obstetrics must be regarded as a branch of surgery.".....
ELEVATION OF OBSTETRICS: "At the present time, Womens clinics and idealistic clinical professors, such as I have sketched, do not exist in the country. Professors of this type would do more to elevate the standards of obstetrics than volumes of writing. They would teach students that the ideal obstetrician is not a man-midwife, but a broad scientific man, with a surgical training, who is prepared to cope with 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 rathole waiting for the rat to escape."
"The present degraded position of this branch of medicine is due to several factors. First, most medical facilities regard it as unfitting occupation for an energetic man; secondly, that an extensive private obstetrical practice is so arduous as to be incompatible with serious professorial and research work; and thirdly, because most ambitious men who take it up regard it merely as a stepping stone to the less arduous and much more profitable gynecology."
H. CHEAPER NURSES: The trained nurse has been of invaluable aid in the development of modern methods of caring for the sick. Unfortunately, the compensation which she demands and deserves puts her beyond the means of those in very moderate circumstances... ...one of the arguments for elevating the status of midwives is that they will serve as both doctor and nurse."
I. TRAINING OF MIDWIVES:
"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. If this has been the case with the relatively intelligent medical student, I must confess great skepticism concerning the possibility of doing better or even as well with the class of women who are likely to become midwives, even if abundant facilities for their training were at our disposal."
"Moreover, the fact that their employment is very restricted in both Boston and Montreal indicates that they (i.e. midwives) are not absolutely necessary and lends additional strength to the argument of those who believe in their ultimate suppression. I am prepared to advocate their gradual abolition, and their replacement by a marked extension of lying-in charities."
"The majority of respondent to my questionnaire appear to believe that midwives at present do less harm than irresponsible practitioner, they could be left alone with comparative safety. I am dubious of developing satisfactory midwives by any means of instruction."
"I know that in taking this stand I shall be in opposition to many earnest workers who think otherwise; but I hope that the deplorable condition of obstetrical instruction for medical students, as revealed by this report may cause them to hesitate before definitely committing themselves to a propaganda advocating extensive training of midwives."
If anything is to be done, I feel very strongly that it can be accomplished only after a long campaign of education--not of midwives--but of the public and its legislators, who must be taught that effective training [of physicians] will be very expensive, as it will require the establishment of special institutions, where long periods of practical instruction can be given, as well as the development of an efficient system of supervision, with powers of punishment, which will be quite contrary to our usual lawless customs.
f. Urge the extension of obstetrical charities---free hospital and out-patient services for the poor, and proper semi-charity hospital accommodations for those in moderate circumstances.
g. Greater development of visiting obstetrical nurses, and of helpers trained to work under them.
h. Gradual abolition of midwives in large cities and their replacement by obstetrical charities.
Transcription of DISCUSSION following
the presentation of Dr. Williams paper
Dr. J. B. DeLee, Chicago: "Dr. Williams paper leaves nothing to be said. He has covered all the points with characteristic exactness. There is no question about it. Medical education in the department of obstetrics is below the standard maintained by teaching in other departments and continues to cry loudly for improvement.
I feel that the statement cannot be controverted that there die annually in the US as a direct and indirect result of confinement, 20,000 women annually. If we think what a furor would be raised in the community if yellow fever were to take off 20,000 human beings in one year, and on the other hand contemplate the equanimity with which the public views this annual loss of 20,000 mothers, the comparison is striking.
The babies: Hundreds of thousands of babies are permanently crippled, either mentally or physically, as the result of improper obstetrical management of their births, and in a goodly proportion the infant becomes blind as the result of carelessness. I wish, however, to emphasize this point, that the number of children becoming blind is very small to the number that are killed and injured by bad obstetrical practice.
What is the cause of all these miserable conditions? There is but one answer. The standard of obstetrical teaching and obstetrical practice in the United States is too low. The public has no respect for the obstetrician. He is looked down upon, not alone by the people but by the doctors themselves. The people will not pay the obstetrician properly for his arduous work. Obstetrics is the hardest branch of medicine to practice. It robs the doctor of his sleep, destroys his office hours, interferes with all his engagements and besides that, the actual work is exceedingly laborious. (F)ew physicians have the opportunity to acquire the dexterity, because the schools ...did not have enough clinical material on which to teach them. The work is so meagerly paid for that a young physician of ability prefers to going to some more lucrative department of medicine, particularly gynecology and surgery."
The public does not honor the obstetrician for his work, does not provide opportunities for him to perfect himself in his art and blames him inconsiderately for his failures. The surgeon is given better facilities for his work .... If you wish proof of this statement, compare the surgical operating rooms in any existing hospitals with the maternity wards of the same hospital. The most desirable and the most beautiful rooms are selected for the surgeon and his every want and comfort promptly provided. On the other hand, the least desirable and out of the way portion of the hospital is assigned to the obstetrician. It is small wonder then that the physicians, students, nurses go out into practice with a low and mean opinion of obstetrics and this to my mind explains the mortality of 20,000 mothers annually in the United States.
We have studied the causes and we have learned the effects. What is the remedy? It is not by educating the midwife to do better work, because we have seen that the mortality in the midwifes practice is little, or no greater, or surely not as great as that in the hands of medical practitioners, and further, those of you who know the material [i.e. class of women] that would come up for the degree of midwife will appreciate the difficulties of ever getting competent service from such women.
The one way to cure these evils is to educate the public to demand a high standard of obstetrics from physicians.
How can this be done? Let us begin with the Womens Clubs in the United States. Let us tell them of the facts we have learned here today. The Womans 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.
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."
Dr. Rachel S. Yarros, Chicago: "As a measure of expediency and as an improvement over the midwife, I recommend the education of the trained nurse to take care of normal cases or to work as an assistant with the obstetrician." [Ed Note: the historical origin of nurse-midwifery]
Dr. George W. Webster, President Illinois State Board of Health, Chicago: "There are only 13 states in the Union having laws in any way governing the licensing and control of midwives. In 14 states the law says that the provision of the medical practice acts shall not apply to [midwives]. In all other states the laws are silent on this subject. I am convinced that the question is not wholly an educational one, but an economic one. In Chicago, the services of a midwife may be obtained for $2.50 [low/middle-class family incomes $700-$1200 a year] and if the service is as good as that of the physicians [average fee $10 -- $15], as Dr. Williams says, they cannot be blamed for accepting it. We must supply something good at an equally low price. We cannot legislature midwives out of existence any more than we can poverty, drunkenness or crime". ...end...
The Antidote -- Giving Women Back Their Dignity
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