California College of Midwives
UCSF Meeting July 30, 1999

The History of the "Midwife Problem"
1910 -1935

Through research of archival documents and the statistical records of the era revealed that the safety of midwifery per se was never in question. The "midwife problem" as referred to by organized medicine was the problem doctors were having in their attempts to secure access to a steady supply of "clinical material" for teaching purposes at the 125 medical schools in the US. The 1910 Flexner Report on medical schools was extremely critical of the lecture format of obstetrical education in the US, compared to Europe where obstetrics was taught in a "clinical" setting. At the time, med students had no hands on experience and as interns delivered only 1-3 babies in the homes of immigrant families.

Obstetrician of the day, Dr J. Whitrige Williams (original author of Williams Obstetrics) stated: "The story of medical education in the country is not the story of complete success. We have made ourselves the jest of scientists through out the world ...." [1911-C, p. 207, TAAPSIM]. A survey of medical schools in 1911 by Dr. Williams revealed that: "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 hospitals this is possible only by having 4 to 6 students examine each patient, and thereby subjecting her to unjustifiable risk of infection. " [1911-B; .p170].

One professor of obstetrics interviewed by Dr. Williams admitted that he had never seen a woman give birth before taking on his role as a professor of obstetrics. Another obstetrician of the time remarked: "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. ... this 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]

In spite of scientific evidence to the contrary, members of organized medicine rationalized to each other that midwives provided substandard care and in their minds this rationale justified the plan to put midwives out of business and to take over their clientele as teaching cases for medical students. What started as a medical education dilemma resulted in an organized campaign by medical politicians which aimed at and very nearly succeeded in eliminating the independent practice of midwives within a ten year span of time.

Midwives were eliminated from practice en masse between 1910 and 1920 (a precipitous drop from 50% to 13% in a single decade -- at time when women did not yet have the right to vote). Sadly this was accompanied by a concurrent increase in maternal mortality rate, which rose by 15% a year and an increase in the birth injury rate by 44%. During this era, the US had the highest maternal and infant death rate of any industrialized country except for Brazil. [Transactions of the Am Association for the Study and Prevention of Infant Mortality 1910-1915].

The problem was that physicians took over the care of midwifery patients without any idea of the philosophy, principle or techniques of midwifery. Instead they related to the care of healthy childbearing women as an opportunity to develop their skills in interventive & surgical obstetrics by routinely using chloroform, episiotomy, forceps and manual removal of the placenta at every normal birth. It is no wonder that a great increase in anesthetic deaths, hemorrhage, infection, brain injury to newborns and long-term gyn complications for mothers followed in the wake of this ill-conceived idea.

Unfortunately it was equally easy to conclude that these bad outcomes indicated that childbirth itself was intrinsically dangerous when in fact the problem was the application of emergency interventions to normal circumstances. This false association fueled the campaign to further medicalize childbirth, especially in replacing midwives with physicians and moving to a hospital only system. It was not until the improved economic status of the US population (starting in 1935) and resulting improved health of the general public and the medical discoveries surrounding WWII (safer anesthesia, antibiotics and safer blood transfusions through blood typing) that this state of affairs was reversed, in part by permitting successful treatment of the complications associated with obstetrical interventions.

The "midwife problem" is not terribly different today. Medical scholars have never corrected the dis-information campaign waged against independent midwifery at the turn of the century. Medical schools still do not teach the traditional wisdom, philosophy, principles and practices of midwifery. In European countries that have better maternal-infant outcomes than the US, med students and interns are first taught about normal birth by midwives before being exposed to the pathology of obstetrics. In the US we neither assign med students to be trained by midwives nor acknowledge that practicing midwives have any form of specialized knowledge or skill sets that would be valuable to physicians. In addition to the historical bias, there is the intrinsic conflict of interest in our medical reimbursement system in which professionals are paid for what they do (whether needed or not) and not acknowledged or reimbursed if they fail to perform "procedures". The deck is stacked against both professions at present.

Our maternity care system needs to be subjected to intense scrutiny and a new national policy adopted that reconciles the professions of medicine and midwifery and that reflects the best of evidence-based practices. However, the unfortunate combination of historical baggage associated with the "midwife problem" and contemporary animosity by the obstetrical profession against midwives leaves both groups with an emotional charge that must be defused before mutually-beneficial progress can occur.

Go on to next in UCSF series

(3) Science, Midwifery Politics & the
Clinical Characteristics of the Midwifery Model of Care
-- more than just "non-intervention

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