The Official Medical Plan to Eliminate the Midwife:  1900 -1930
Final part - Five	by faith gibson, LM, CPM, Community Midwife

V. Historical Consequences:
The purposeful elimination of the independent practice of midwives and 
the accidental suppression of the historical discipline of Midwifery

Sadly the result of this successful strategy to suppress and eventually abolish the independent practice of midwives was to inadvertently eliminate the safer and non-interventionist principles of physiological management.

~ "We have had a small but convincing demonstration by the Frontier Nursing Service of Kentucky of what the well-trained midwife can do in America. .... The midwives travel from case to case on horseback through the isolated mountainous regions of the State. There is a hospital at a central point, with a well-trained obstetrician in charge, and the very complicated cases are transferred to it for delivery". [1937-A]^136

~ "In their first report they stated that they have delivered over 1000 women with only two deaths -- one from heart disease, the other from kidney disease. During 1931 there were 400 deliveries with no deaths. Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after analyzing the work of the Frontier Nurses’ midwifery service in rural Kentucky, made the following statement on May 9, 1932:

~ "The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life."

~ "What are the advantages of such a system? It makes it economically possible for each women to obtain expert delivery care, because expert midwife is less expensive than an expert obstetrician. Midwives have small practices and time to wait; they are expected to wait; this what they are paid for and there they are in no hurry to terminate labor by ill-advised operative haste." [1937-A] {*}

VI. Misplaced Priorities

These statistics identify a total of 70,000 unnecessary deaths per year, year after year, that were simply preventable by the application of a well-known, globally-respected principle -- that of skilled midwifery care. One half of all maternal deaths and 1/5 of all infant deaths during the 1920s and 1930s were avoidable -- "excess" mortality created not by aberrant biology or even abject poverty but the prejudices of "medical men". In spite of the fact that this situation was so clearly articulated by a physician of impeccable credentials and reported more than 60 years ago, the resistance to midwives and the midwifery model of care continued to be ignored at best and eliminated where possible.

A more modern-day example of this occurred as a result of a pilot nurse-midwife program established at Madera County Hospital (California) from July 1960 to June 1963 [Levy, et al, 1971]. The program served mainly poor agricultural workers. During the three year program, prenatal care increased, and prematurity and neonatal mortality rate decreased at the county hospital. After it was discontinued by the California Medical Association, the neonatal mortality rate increased even among those women who had received no prenatal care, which suggests that the intrapartum care delivered by nurse-midwifes may have been far more skillful that delivered by physicians. Prenatal care decreased while prematurity rose from 6.6 to 9.8% and neonatal mortality rose from 10.3 to 32.1 per 1,000 live births. It is concluded that the discontinuation of the nurse-midwives' services was the major factor in these changes. [Levy, et al, 1971]

Since the early 1940s, our maternal mortality statistics have improved dramatically, due primarily to an improved standard of living and also to the development during the Second World War of antibiotics, cross-matching for blood transfusions and safer anesthetics and surgical techniques. This meant that many of the complications caused by obstetrical intervention could be successfully treated. But our perinatal death rate (up to 28 days after birth) in the United States is still at the bottom of the pile -- 23rd out of 25. Our operative delivery rate, -- sky-rocketing cesarean sections rate -- is the 2nd highest in the world. Again, the US is at the bottom -- 23rd out of 25 countries. On average, one out of every three mothers giving birth in hospitals and cared for by obstetrical services finds herself having major abdominal surgery. The maternal mortality rate for Cesarean section is 2 to 6 times what it is for spontaneous vaginal birth.

---

Deaths per 100,000 women

Cesarean Section:	31	ratio of 1: 3,225
Breast cancer	26	ratio of 1: 3,846
Most *dangerous occupation	22	ratio of 1: 4,545
Auto accidents	20	ratio of 1: 5,000
Vaginal birth	6	ratio of 1: 16,666

*Taxi driver

The Obstetrical Philosophy of Pathologic Dignity

~"The quality of obstetrics was hampered not only by the past failing of medical education but perhaps more so by the nature of the campaign to eliminate the midwife. To discredit the competence of the midwife as a birth attendant, obstetricians had argued that pregnancy, labor and delivery were not normal physiological processes but so fraught with danger that only an obstetrician could safely attend birth." [DeVitt, MD; 1975]

This not only impinged on midwives and midwifery historically but by the 1970s, obstetricians, successful as they had been in abolishing independent midwifery, turned this same argument against the provision of maternity care by general practitioners and family-practice physicians. Through the influence of obstetricians on hospital policy-setting committees, not only midwives but family practice doctors have, by and large, been prevented from attending normal births in the hospital.

~ "the philosophy underlying the campaign to eliminate the midwife created a self-justifying bias towards medical interference in birth. Every time the physician applied forceps or performed a Cesarean delivery, he proved to himself that birth was pathologic and therefore he, the obstetrician, was necessary." [DeVitt, MD; 1975]

~ "A final underlying issue which contributed to the opposition to the midwife was the remaining 19th century bias of the medical profession, particularly obstetrics and gynecology, against women. the nature of this bias, a contempt for women’s intelligence and physical stamina has been well-documented by Ehrenreich and English (1973), Complaints and Disorders. The vicious tone of the physicians’ articles on "the midwife problem" surely reflect this general contempt for women. This distortion of facts, exemplified in previous quotations, demonstrates that at least the most vocal opponents of the midwife were unable to evaluate her practice objectively. As long as obstetricians sought to gain the esteem of the "medical men", they could not tolerate competition by the midwife." [Neal DeVitt, MD; 1975] {*}

Contemporary examples of this are found in a letter dated August 1, 1977 by the Chief of Obstetrics of a major teaching hospital on the West Coast arguing against a bill to license and regulate non-nurse midwives:

~ "If we want an increase in cerebral palsy, mental retardation, extended hospitalizations for mothers undergoing infections, fistulas, hemorrhages, and other severe and disabling results of neglected childbirth, only then could one endorse bill AB 1896." Heinrichs, MD., Ph.D.

In stating that the "...decline of American midwifery was both a legal and sociological phenomenon". Dr. DeVitt notes that because the US lacked a national policy acknowledging the social value of independent midwifery, there was no countervailing force to offset the organized politics of state and local and national groups intent on using their political power to the determent of midwives.

~ "Where midwifery was outlawed, its practice was gradually eliminated by enforcement of the law. In other jurisdictions midwives were gradually eliminated from practice by ever stricter examinations. Such a policy was followed in Washington, DC, where the proportion of births attended by midwives decreased from 50% in 1896 to 5.5% in 1918." [Chaplin, MD, 1919] {*}

~ "...there is evidence that a strong independent midwifery profession is an important counterbalance to the obstetrical profession in preventing excessive interventions in the normal birth process." [WHO, Wagner, MD; 1988]

~ "Midwifery provides a balance between family and (the) medical perspective on birth. To negotiate and balance the different meanings and perspective of birth within the health care system, it is essential for midwives to have a legitimate and powerful role within the system. Midwifery should be powerful enough to influence both the nature and the delivery of services. This, I believe, would greatly enhance maternity care, which ultimately is the crux of the matter..." [Page, SM, Director of Midwifery, Oxfordshire, England, 1988]

                      ================================epilogue===============================

	Fact Versus Prejudice Revisited

Having closely examined the classical ‘Midwife Problem’ and the organized campaign to eliminate traditional forms of independent midwifery, we are called upon to face disturbing facts -- the elimination of midwives was never justified on the grounds of maternal-infant safety or the public good. It was and is an injustice that seeks remedial action. The contemporary problem is this to eliminate the prejudices rather than the midwives.

Ultimately, a maternity care system is judged on its results -- the number of mothers and babies who graduate from its ministration as healthy (or healthier) than when they started. We can no longer afford to let our prejudices get in the way of the plain facts -- governments that look to midwifery care as the standard for normal births have statistically improved outcomes. This cost-effective and efficacious form of maternity care serves the social and emotional needs of healthy childbearing families far better than our expensive and inflexible high-tech model. Coupled with these social and emotional needs are the restraints of modern-day economic realities, and making reform all the more imperative. When more than 50% of all hospital admission for persons under 65 years of age (including both men and children patients) are for childbirth, we must come to terms with the economic impact of the ‘childbirth business’.

The missing link is respect by the medical community for what it might learn from midwives. In the rush to "sanitize" contemporary midwifery with hospital-based, medicalized training programs and dependent licensure under physician supervision, obstetricians and others are acting out the same prejudice used against midwives during the early 1900s. It is a prejudice which erroneously assumes that we midwives of whatever background are uneducated, untrained, unskilled and undesirable and must have our intuitive knowledge and experiential-based skills excised like a malignant disease requiring strong medicines and radical surgery.

~ "That Socrates' mother was a midwife bears testimony to the honorable nature of such a profession at a time when civilization in one of its highest forms was at its summit." [1911-G; BakerMD, p. 232

One of the current criticisms of non-nurse midwives is the ‘lack of formal education’ and the absence of licensing for direct-entry midwives. However, it is important to remember that a central strategy of this medical campaign to eliminate midwives was to block both the training and licensing of midwives. The result is that formal training in traditional (non-nurse) midwifery has not been available for 60 years and so instead of a modest number of formally educated and certified midwives, we have a larger number of ‘lay’ midwives which, unfortunately, includes a small number who are inadequately trained and who occasionally bring harm to the mothers or babies they serve. However, physicians are not blameless. Not only can obstetrical care bring occasional harm but the stiff-armed response of the obstetrical community continues to exacerbate the problem by preventing the establishment of training programs for student midwives, licensing for new midwives and interactive collaborative relationship between practicing midwives and physicians.

~"There is no alibi for not knowing what is known"
J. Rovinsky, MD -- a quote from the foreword of Davis Obstetrics:

Midwives are suggesting, in the strongest of terms, that an exchange of expertise is in order. It is as much the responsibility of physicians to be familiar with the time-honored philosophy, principles and skills of midwifery as it is the duty of midwives to know the principles of anatomy and asepsis. Midwives are in agreement that modern obstetrics has much to teach and much to contribute to the wellbeing of the families it serves. As midwives we have already availed ourselves of both formal and informal study of obstetrical science. Likewise, the honorable but unassuming traditions midwifery -- the art of being "with women" -- the quietness of spirit, the patience with nature, the intimacy skills which serve childbearing families so well are also of great value to the bio-medical sciences. We believe that physicians cannot begin to examine their prejudices without specific information on the nature of these principles and the opportunity to build personal and professional relationships with practicing midwives.

The Late Dr. Galba Araujo, formally professor of obstetrics from Brazil, in an article urging an "articulated model of midwifery" into contemporary obstetrics stated:

~ "We have learned much from the traditional (midwife) and respect is mutual between our parallel groups. We have learned to teach our (obstetrical) students less invasive delivery and above all, to use the vertical position for the mother. Perhaps this is the most valuable lesson among the many we have learned."

In spite of the fears of many within the obstetrical community, midwives do not represent a feminist conspiracy to eliminate the obstetrician. Quite the obverse -- midwives seek to augment, supplement and complement the contemporary medical model of care. The jewel in the crown of independent midwifery is that it is not intrinsically in conflict with the true purpose and glory of obstetrical care -- the compassionate correction of dysfunctional states and the treatment of pathological ones. The immutable standard of maternity care is the same the world over and through out history, it is the same in every language -- the goal is and will remain the practical wellbeing of the mothers and babies it services... Here on the brink of the 21st century, the first duty of maternity caregivers of every educational and experiential background must be to bring about a cooperative and complimentary system that truly functions in the best interest of childbearing families.

The time to eliminate prejudice is upon us.

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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last updated 08/11/07 12:59 AM