The Story behind the Story

This material was originally complied to accompany an article reporting on the a University of Washington study confirming the efficacy of midwifery care. The study's main author is Dr. Roger Rosenblatt, the Vice-Chairman of the Department of Family Practice Medicine at the University of Washington School of Medicine. He was interviewed on April 21st on National Public Radio news program "All Things Considered" by Ray Swaraz. During that interview, Dr. Rosenblatt was very complimentary to the care of midwives, acknowledging that they had much lower rates of Cesareans for low risk mothers (40% less) than care of by physicians. Mr. Swaraz asked Dr. Rosenblatt why the medical profession "frowned on midwives" for all these years. Dr. Rosenblatt's replied:

" I don’t think its fair to say that they frowned on it. We’re a very heterogeneous bunch in the medical profession. But many have frowned on it because there is a tradition in our country where at some point midwifery was not terribly safe. 

We came in with medical obstetrics and we’ve made it an incredibly safe discipline. So I think there is some residue of that. But I think that things have changed now and its time to look again at how we can all work together as a team."

I quite completely agree with and applaud the last portion of this statement about "things have changed" and it being "time to work together as a team". The statement is somewhat mollifying to the obstetrical world and useful to help defuse the historical tension between our respective groups. From that standpoint it is a welcomed contribution to midwifery. But technically, it is not a true representation of historical events. The following story is an accurate recounting of the events that brought about the elimination of independent midwifery. It is long but fascinating story, well worth the time it takes to read. Your constructive feedback is welcome!

There are 5 parts to this story. You will have to loads them sequentially
by hyper-linking at the end of each segment.

Or you can go directlly from here to: ~part 2, ~part 3, ~part 4, ~part 5

General Citations and Bibliography

The value of midwifery-based maternity care for healthy women, obstetrical care for 
complicated pregnancies, liberal breastfeeding, and valuing of the parent-child bond have long been
documented in maternal-infant statistics. These cost-effective methods have always
been strongly associated with low rates of mortality and morbidity and the
long-term wellbeing of mothers and babies.

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The Research Materials Used to Write
"The Official Plan to Eliminate the Midwife"

The following historical account comes primarily from documents published in professional journals between 1900 and 1930. The majority of the material was published in the "Transactions for the Study and Prevention of Infant Mortality" 1910 -- 1915. This archival material records the historical blueprint of an official campaign to do away with the independent practice of midwives. Also faithfully recorded in these journals was the efficacy of care by midwives of the era, the history of the school for midwives in New York City and its excellent statistics, and the increase in maternal and infant mortality that occurred as midwives were progressively eliminated from practice. These documents, written at a time when women did not have the right to vote, were intended for "professional eyes only".

I cannot thank the library staff at Stanford University Medical Library enough for their assistance in helping me access these very important but ‘dusty’ resources so that on the eve of the 21st century they could, after almost a 100 years of obscurity, be made publicly available through the Internet. It is my personal and professional opinion that we are best served by first understanding and then leaving these 19th century concepts of gender-based subservient roles behind us as we step forward into the next century. While this story may speak of an ignoble past, midwives as a group are dedicated to stepping away from it without recrimination and stepping forward into an ennobling future, arm and arm with the medical profession.

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 wellbeing of the mother and baby first.

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The Individual Midwife vs. the Discipline of Midwifery

Before embarking on the overview, it is important to make some vocabulary distinctions so that the story does not become unduly confusing.

In the following archival material you will hear repeatedly about the "the Midwife Problem" and "the Elimination of the Midwife" but not about the elimination of midwifery, per se. There was an important historical difference between the practice of "midwifery" as the art and science of normal maternity care for healthy women as provided by both the midwife and the physician (often referred to at that time as a ‘man-midwife’) and the "the midwife problem", which referred to the elimination of midwives FROM the practice of midwifery. Members of the medical establishment, especially professors of obstetrics (lead by Drs. DeLee and Williams) wished to eliminate the competition of midwives but did not initially intend to actually eliminate midwifery as a distinct, historical discipline.

Unfortunately for the rest of us, this campaign to eliminate the midwife did irreparable damage to the principles and philosophy of midwifery by insisting that "only a surgeon" could adequately or safely provide birth services. Eventually doctors began to believe their own propaganda and to preach it to the public. For instances, Dr. Holms in 1920 stated that "Only the properly trained physician who has acquired surgical technique with specialty training in obstetric physiology and pathology is competent to circumvent the many ills of childbirth."

As a result, the discipline of midwifery, -- its philosophy, its principles, and its skills such as 'patience with nature' and vaginal delivery of breech babies -- has itself been inadvertently destroyed and we were left, in its place, with a national maternity care policy which ignores the non-interventionist principles of midwifery and is instead predicated on high-tech, hospital-based specialist care. This replaces an inexpensive  family-centered experience costing apporximatley $1200 to $2400 with a high tech, high stress labor and delivery running $10,000 to $30,000.

Below is a functional definition of the historical discipline of "man-midwifery" by one of the physicians of the era. It is one which I personally would like to see returned to its rightful place of honor in our national healthcare policy.

"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]

I believe it is an excellent definition of collaborative practice between physicians of all backgrounds and midwives. In light of Dr. Rosenblatt's study it could easily be interpreted to assume that the best way for a physician to "secure" these attributes of maternity care for healthy women experiencing normal pregnancies would be to recommend the care of midwives.

~ "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 and prejudices." [1925-A; Hardin, MD p. 347]

The Official Medical Plan to Eliminate the Midwife

~ "..... 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; RuckerMD Rebuttal by Dr. Levy, p. 822]

~ "The training of midwives in Germany, where they are required to spend 6 months in a government obstetric hospital under the instruction and supervision of trained obstetricians, is far superior to that which the great majority of physicians receive in this country before graduation." 1925-A

I. The Story of the Hundred Years War Against Midwives

The master plan to abolish midwives was not based on any categorical deficiency of midwives or a new medical "discovery" that made the principles and skills of traditional midwifery obsolete. Historically, in the US and elsewhere, the practice of midwives was safer than the same kind of care as provided by physicians.

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

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

~ "It may be argued that the effect upon the infant of good and poor obstetrics would appear principally in the deaths under one month of age and that in this group we will find the highest mortality among the births attended by midwives. Strangely enough, it appears that especially in this age group the infant mortality is lowest for infants attended by midwives and highest among those delivered by hospitals. .... hospitals delivered 20% of the babies that died under one month of age but attended only 12% of the births of the city.[1917-B; LevyMD; p.44] {emphasis added}

~ "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. 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 {emphasis added}

~ "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." [Van Blarcom, MD; 1913]

~ "Clearly the midwife seemed to be the safest birth attendant" [DeVitt, MD; 1975]

None the less, influential medical politicians embarked on a well-documented, well-coordinated, and well-financed strategy to eliminate the midwife from the practice of her own profession. After the plan to suppress midwives was implemented, the maternal-infant mortality in US rose dramatically (15% a year) in many places in direct proportion to the increase in physician-attended births and a corresponding drop in midwife-attended births. According to Dr. Ziegler:

~ "As to maternal mortality, ...during 1913 about 16,000 women died..; in 1918, about 23,000...and with the 15% increase estimated by Bolt, the number during 1921 will exceed 26,000." [ZieglerMD1922-A]

~ "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 for Holland, Norway, Sweden, Denmark is far superior to our own. Why? It cannot be because of our ignorance, for in the scientific phases of obstetrics, America is one of the world’s leaders; 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] ^133

~ "What about the conduct of labor in the two regions? Here is 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. The Scottish Report states: "In as high a proportion as 24 percent of all birth recorded during the six months’ intensive survey, delivery was not spontaneous." Fifty-one percent of all the maternal death in Scotland occurred in the 24 percent in which the labor was operative. Let is compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. "In Sweden the interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland ..... it is under 1 percent." [1937-A] ^134

~ "What is responsible for this vast difference in operative rates? ... Analgesics 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] ^135 {emphasis added}

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]

Dr. Neal DeVitt, MD, a contemporary scholar who extensively researched this topic, proposed in his 1975 doctoral thesis "The Elimination of Midwifery in the United States -- 1900 through 1935" proposed "that the slow decline in infant mortality would have been greatly accelerated had not the campaign to eliminate midwives been undertaken." 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. A 1927 study by Kosmak noted that the incidence of operative deliveries in the US was 10-30% higher than in Scandinavian countries, where midwife-attended birth was the norm (85%), and which enjoyed significantly lower rates of maternal-infant mortality and a 4% operative delivery rate.

~ "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]

Fact versus Prejudice

From 1890 to 1930, many articles were published by physicians in professional journals discussing the "The Midwife Problem". The "problem" discussed was the one physicians were having in their campaign to eradicate midwives, who were characterized as providing dangerously inadequate care and were identified as the reason the US had one of the worst maternal mortality rates of any industrialized country.

In 1900, 50% of births in the US were midwife-attended. Most European countries, especially Sweden, Denmark and Norway, had an 85% rate of midwife attended births. By 1935 the percentage in the US was reduced to 12% and by 1972, it was only 1%. Presently (1997) those same Scandinavian countries have 70% midwife-attended births.

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:

~"...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)

In stark contrast to this White House report on the social value of independent midwifery is a 1975 quote in the New York Times Magazine which characterizes the classical obstetrical version of the relationship between midwives and obstetrical medicine.

~"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 attached 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]

The statement quoted above represents widely diverging opinions in a controversy that has not been publicly examined on a point-by point basis.

~"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 know of anatomy and asepsis at 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 (obstetricial) profession was thought to be threatened by the practice of midwifery" [Dr. Neal DeVitt, MD, 1975]

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.

~ "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]

~ "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]

While modern-day observes would agree that obstetrics currently enjoys great professional status, it must be remembered that "Man-Midwifery", as it was called throughout out the 17th, 18th and 19th centuries, was considered the poor step-sister of ‘modern-medicine’, cast aside as a dubious form of "woman’s work" not worthy of the attention of formally-educated "medical men". As late as 1915, Moran wrote that

"Obstetrics is the most arduous, least appreciated, least supported, and least compensated of all branches of medicine".

Continue on to part 2

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General Citations for Above Article

last updated 06/20/06 11:36 PM