by faith gibson, LM, CPM., community midwife

II. Motives of the Medical Establishment for the Suppression of Independent Midwifery

The first official act to limit the practice of midwives was a law passed in Rochester, NY in 1896. The wording of this NY law was used verbatim in 1917 for a midwifery statue passed in California. In 1974 it was incorporated into the California nurse-midwifery law and most recently, it became a central part of the California direct-entry statute. While the campaign to suppress independently practicing midwives is now in its 101st year, the actions taken by the medical establishment to "Eliminate the Midwife" occurred primarily between the years 1910 and 1920 -- at a time when women did not yet have the right to vote. During this decade the number of midwife-attend births fell from approximately 50% to about 15%. By 1935, the national average dropped to only 12% and nearly all of those were informally trained granny midwives in the deep South.

The underlying motive was predicated on a desire was to compete with German medical schools, which, unlike the US, had historically included clinical training in obstetrics and enjoyed a superior reputation with the European aristocracy.

~ "In general, ...the medical schools in this country and 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." 1911-B; Williams, MD p. 178

~ "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." [1912-B, p.224]

The purpose of eliminating the practice of midwives was to make their clients available as additional ‘clinical material’ (teaching cases) for the training of medical students.

~ "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 {teaching} material." [1912-B, p. 226

Illustrative of the sentiments of the day, which generally believed that each midwife attended birth was a "waste of clinical material" are the following quotes.

~ "I should like to emphasize what may be called the negative side of the midwife. Dr. Edgar states that the teaching material in NY is taxed to the utmost. The 50,000 cases delivered by midwives are not available for this purpose. Might not this wealth of material, 50,000 cases in NY, be gradually utilized to train physicians?" [1911-D, p 216]

~ "Another very pertinent objection to the midwife is that she has charge of 50 percent of all the obstetrical material [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.." [1912-B, p.224]

~ "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 are sent 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. 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." [1912-B, p.226] {emphasis added}

Interwoven with the practical dilemma of not enough teaching cases to go around for all the midwifery, medical and nursing students of the day, was a deep prejudice against midwives that went beyond any rational argument. Comments by various physicians of the day are:

Garrigues (1898) "pestiferous"; Gerwin, (1906) "the typical, old, gin-fingering, guzzling midwife, ... her mouth full of snuff, her fingers full of dirt and her brain full of arrogance and superstition"; Mabbott (1907) "un-American"; Emmons and Huntington (1912) "the overconfidence of half-knowledge, ...unprincipled and callous for the welfare of her patients"

~ "The question in my mind is not "what shall we do with the midwife?" We are totally indifferent as to what will becomes of her...[1912-B, p.225]

~ "The midwife is a relic of barbarism. In civilized countries the midwife is wrong, has always been wrong. The greatest bar to human progress has been compromise, and the midwife demands a compromise between right and wrong. All admit that the midwife is wrong." [1915-C; DeLeeMD.p. 114]

~ "Any scheme for improvement in obstetric teaching and practice which does not contemplate the ultimate elimination of the midwife will not succeed. This is not alone because midwives can never be taught to practice obstetrics successfully, but most especially because of the moral effect upon obstetric standards." [The Teaching of Obstetrics", American Association of Obstetrics and Gynecologists]

Of this era, Dr. Neal DeVitt, MD [1975] remarked that

"Most of the medical men had too much contempt for the midwife and too little respect for fact. The quality of the debate was poor. Evidence against the midwife was largely anecdotal or unsubstantiated opinion."

These deep prejudices were combined with equally deep professional aspirations that were obviously being thwarted. For example, the comments below by Dr. DeLee are very revealing:

~ "The midwife has been a drag on the progress of the science and art of obstetrics. Her existence stunts the one and degrades the other. For many centuries she perverted obstetrics from obtaining any standing at all among the science of medicine." Dr. DeLee, 1915,-c, p. 114

~ "Obstetrics is held in disdain by the profession and the public. The public reason correctly. If an uneducated women of the lowest class may practice obstetrics, is instructed by doctors and licensed by the State, ( attendance at a birth) certainly must require very little knowledge and skill ---surely it cannot belong the science and art of medicine."

~ "If the profession would realize that parturition, viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention."[1915-C; DeLeeMD p.117]

~ "The midwife never has and never can make good until she becomes a practicing physician thoroughly trained; that midwives should not be licensed save in those states where they are so numerous that they cannot be abolished at once; and concluding with the third question by showing how midwives can be gradually abolished." [1911-C; Emmons & Huntington,MD, p. 199

III. Medical Education and its Relationship with the Campaign to Abolish the Midwife

Only with the knowledge of the status of obstetrical science in the United States in the early 1900's can one reasonably evaluate the obstetricians' campaign to eliminate the midwife. Obstetrical education in the early 1900s in United States was not based on clinical training -- that is actual hand-on practice, but rather textbook learning, lectures by professors and "observation" of care rendered by others.

~ "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." 1911-B; WilliamsMD

~ "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 .... -- 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." [1911-B; WilliamsMD p. 178]

~ "In 1911, the great American obstetrician, J. Whitridge Williams, (original author of "Williams Obstetrics"), completed a survey of obstetrical education in United States medical schools. Williams found that more than one-third of the professors of obstetrics were general practitioners. ‘Several accepted the professorship merely because it was offered to them but had no special training or liking for it.’ 13 had seen less than 500 cases of labor, 5 had seen less then 100 cases and one professor had never seen a woman deliver before assuming his professorship. Several professors of obstetrics were not able to perform a Cesarean section. [DeVitt, MD, 1975] {*}

Before a (medical) student was licensed to practice, Dr. Williams reported that :

~ "the actual figures show that in 25 schools, each student see 3 (deliveries) or less, in 9 schools, 4-5 cases and in 8 others, 5 or more cases, while in some of the smaller hospitals this is possible only by having 4-6 (medical students) examine the each patient..."

Dr. Whitridge Williams, the original author of "Williams Obstetrics" was highly critical of this situation:

~ "The generally accepted motto for the guidance of the physician is ‘primum non nocere’ (in the first place, do no harm), 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 ... midwife...." 1911-B; WilliamsMD p.180

~ "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 (midwives) and the abolition of medical practitioners, which would be a manifest absurdity." [1911-B; WilliamsMD]

Birth Attendant:		Midwife	Physician
Total Births (%):		52%	48%
Stillbirth:		10%	90%
Neonatal Deaths:		35%	65%

[Van Ingen(in Baker, MD; 1913, for NYC]

~ "Baker [1913] reported that for New York City as a whole, midwives attend 40% of all births but had only 22% of the maternal deaths from puerperal sepsis while physicians, with 60% of the births, had 69% of the deaths from sepsis in their practice. In these surveys the death was attributed to midwife practice if she was ever present at the labor even if she turned the case over to a physician or hospital" [DeVitt, MD; 1975] {author’s note: these figures actually reflect three categories, the last of which has some overlap -- midwife/home, physician/home and hospital/medical student-doctor, which accounts for the missing percentage points}

Levy examined birth-related mortality in Newark, NJ for 1921 and found a similar relationship to that of Van Ingen’s survey of Manhattan.

Birth Attendant:	Midwife/Home	Phys/Home	Hospital
Birth percentage	38%	30%	31%
Puerperal Deaths:	13%	34%	52%
Neonatal MR/1000	32%	40%	34%

~ "With these results of the midwifery surveys and of Williams’ survey of obstetrical education, the debate over the future of the midwife began. Against the midwife were obstetricians who favored immediate abolition of the midwife no matter what the consequences [most were from Boston - Noyes, 1912], or who favored gradual abolition through stricter regulation [Williams, 1912; Ziegler, 1913]. For the midwife, were public health officers and Southern obstetricians who realized that the midwife could not be eliminated immediately and thus wished to train her [Nicholson, 1917; Hardin, 1925], and a few physicians [most notably Abraham Jacobi, 1912] who wished to establish midwifery schools in the United States to make the midwife a permanent institution in the US as it already was in Europe." [DeVitt, MD, 1975]

Continue on to part three

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last updated 06/12/06 01:29 PM