Historical Perspectives Series
Official Medical Plan
by faith gibson,
For Excerpts from archival documentation (1881-1932)
Historically, the practice of midwives was far safer than the same kind of care provided by physicians. None the less, the medical community embarked on a well-documented, well-coordinated, and well-financed campaign to eliminate the midwife from the practice of her own profession. The master plan to abolish midwives was not based on any categorical deficiency of midwives or a new medical "discovery" that made midwifery skills obsolete. Instead, the abolition of midwives was undeniably based on the self-interest of the medical community who wanted the "clinical material" of midwives for the training of medical students. The underlying motive was to compete with German medical schools, which included clinical training in obstetrics for their students and enjoyed a superior reputation with the European aristocracy. In the early 1900s, obstetrical education in the United States was not based on actual hand-on practice (i.e. clinical training), but rather textbook learning, lectures by professors and "observation" of care rendered by others. This meant that many new physicians began a general practice, which included childbirth services, without any practical skills. As a result, the USA had one of the worst maternal-infant outcomes among the 25 industrialized countries and was considered something of a "laughing stock" among the "First World" countries.
This resulted in a rather dubious plan for up-grading medical education at the expense of midwives and childbearing women was which was proposed by a small number of influential physicians representing the interests of medical schools. They sought to increase the status and income of physicians and promote a more flattering "scientific" image of the profession of medicine. However, this illogical recommendation did not itself have any scientific basis. Further more, it required ignoring world-wide statistics for maternal mortality and morbidity which argued against such a plan.
At the time this hostile-takeover of normal maternity care was being engineered by American physicians, the five industrialized countries with the best maternal-infant outcomes had midwifery-based models of care for healthy mother and obstetrical care for complicated ones. The five that had the worst had physician-centered maternity systems. The US was in the ignoble position of being in the bottom five. It is an interesting note that Germany itself was one of those countries that had a midwifery-based system in the early 1900. Even today, German law requires the presence of a midwife at every birth, even when obstetrical care by a physician is necessary. Midwives have historically been recognized as guardians of normal birth and a necessary aspect of safe maternity care, providing laboring mothers with a vital quality of emotional support that would otherwise be absent.
The strategy to abolish the profession of midwifery as practiced by midwives was multifaceted and included a legal, legislative and public education approach described as "elevating the public conscience". This propaganda campaign misrepresented the dangers of childbirth and inflated the abilities of medically-based care to eliminate them, while denigrating midwives.
The campaign also included the idea that chloroform and the routine use of forceps were an important "improvement" in maternity care and that it was unethical to deny such "advantages" to the clients of midwives. Women did not have the right to vote at this time and the common perception was that the practice of midwives, (by mere "women") reflected negatively on physicians. The theory was that if a mere woman, not formally educated in medicine, could deliver babies, then childbirth managed by doctors was not a really "respectable" practice of medicine nor worthy of a higher fee than the customary pittance paid to the midwife ($5-10).
The legal and legislative aspects of the campaign included a strategy to make the practice of midwives illegal where every possible. In areas where midwives has already achieved legal status, the tactic was to abolish them by ever-escalating educational requirements and regulatory controls. Furthermore, it included a policy preventing the establishment of midwifery training programs and the licensing of midwives. This was to keep midwives from acquiring the legal protection of an independent profession which would have established normal maternity care as the legal domain of midwives (i.e. requiring physicians to become trained in midwifery in order to provide pregnancy care to healthy women). Licensure status would also have required physicians to respond to requests from midwives for medical assistance in complicated cases and established legal penalties for those doctors who did not comply.
The successful abolition of midwives also depended on developing a low cost substitute for the integrated care of midwives. This was achieved by organizing obstetrical charities, financed largely by the Rockefeller and Carnegie foundations, to provide free antepartal clinics during pregnancy, free hospitalization in charity wards for birth and free obstetrical care by medical students as a part of their formal education.
Many physicians of the day insisted that midwives were ignorant, dirty and dangerous. In truth, a significant number of midwives (40-60% in many localities) had been formally educated in European schools of midwifery. These highly-regarded training programs required midwifery students to manage a minimum of 20 deliveries under the watchful supervision of their instructors.
At this same time, medical students were only required to observe 6 deliveries and often graduated from medical school with virtually no clinical (hands-on) 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. Whatever real or imagined "deficiency" in midwifery education may have existed during this era, the obvious ethical response would have been to support the establishment of midwifery training programs.
Obviously not all physicians of the day were fooled by these political motives masquerading as a high ideals. Well-documented criticisms were recorded in medical journals of the day, complete with tables of compelling statistics clearly demonstrating the accuracy of their observations. Many midwife-friendly public health officials and physicians who managed midwifery training programs and knew first-hand of the excellent success of skilled midwives were vocal on behalf of midwifery and the childbearing mothers served by midwives. Unfortunately, this crucial information was ignored by medical politicians intent on abolishing the practice of midwives to the gain and aggrandizement of their own profession.