ELIMINAtION OF ThE MIDWIFE ~ part 3 ~ 1912

by faithgibson on September 22, 2012

American Association for Study and Prevention of Infant Mortality

Transactions of the Third Annual Meeting
Cleveland, Ohio October, 2-5, 1912
pages 222-237 

Part 3 ~ Criticism of hospital monopoly over ‘clinical material’ & recommendations for improving clinical training by state-sponsored welfare payments for obstetrical care

Staff physicians in hospitals and dispensaries, who are given a monopoly of clinical material and, therefore, possess exceptional opportunity for the development of skill and the establishment of a reputation, should not be allowed to use their positions to gain a monopoly over private patients as well. This is the great evil of the present hospital system and can be prevented only by putting staff physicians and their assistants upon salaries, and requiring them to devote their entire time to the work of the hospital, to research and to teaching. In the larger cities where medical schools exist, all patients for whom the State is responsible, or as many thereof as may be necessary, should be cared for in the hospitals in which the staff positions are held by members of the medical faculties.

In this way a tremendous amount of clinical material would become available for teaching purposes, and students and practitioners of medicine would be given an opportunity of securing any desired amount of training in chosen branches of medicine, while the patients themselves would receive the most efficient service at a minimum cost to the State. Nothing would be taken from the physicians in the way of income, their opportunities for advanced medical training would be much increased, and the medical heads of such hospitals would become invaluable public assets as teachers, investigators and consultants. The salaries of the staff physicians and of the clinical members of the medical faculties could be provided, if necessary, by fees from the necessary number of private patients.
 The vast majority of private patients should, however, be cared for in private hospitals supported by private or corporate capital. No one objects to any physician making all the money to which his skill and reputation entitle him, but he has no right to do so on the investments of public moneys.

From what has been said it will appear that the elimination of the midwife is to be brought about in time through the establishment of obstetric charities consisting of maternity hospitals and maternity dispensaries, with all that goes with them in the form of social service, visiting nurses, prenatal work, relief work, etc. The hospital is to care for all who, for one reason or another, cannot secure proper attention at home, and the dispensary for those who are delivered at home. The majority of women will always be cared for at home, and it is desirable that they should be when conditions permit it. A mother with a number of children cannot usually leave them to advantage, and while it is true that physically she cannot and should not care for them, her presence in the home is necessary to order and discipline. Then, too, the cost of caring for patients in hospitals is much greater than in their own homes. Dispensary patients, moreover, are more likely to do for themselves all that they are able to do, and thus be not so entirely dependent upon help. Both the hospital and dispensary should be in charge of one and the same head in the form of a medical director and in medical centers both institutions should be a part of, or closely affiliated with a medical school.

In cities of the first and second class, especially where medical schools exist, the midwife can, in time, be entirely eliminated through the establishment and extension of obstetric charities—hospitals and dispensaries. The vast majority of cases, unable to pay physicians, can be cared for by medical students, provided the requirements for graduation are increased so as to give students the necessary training in obstetrics. My own feeling is that before going into private practice each student should be required to deliver personally not less than fifty cases under careful supervision, and should also be taught to do upon the living subject all the obstetrical operations which the granting of his diploma gives him license to perform; as I hold that it is little less than criminal to permit practitioners of medicine to jeopardize the life and health of human beings by performing upon them operations which they had not done, and perhaps had never seen performed in their student days.

The average practitioner who gains his experience in obstetric operating solely upon his own responsibility rarely ever learns to do it safely, and, therefore, always remains a menace to his patients, and should he eventually become an accomplished operator, his knowledge has been gained at the cost of much invalidism and of a number of deaths. My argument, therefore, is that if he must acquire the knowledge, it is much better that he should do so under careful supervision and instruction.

The public should learn that it is the duty of every citizen, if for no other reason than that of the safety of his own family, to insist that students of medicine be not only supplied with clinical material, but that they be required to utilize it in acquiring the knowledge which is indispensible to efficiency in the practice of obstetrics. If the midwife cases and such others as are dependent upon public charity were used for teaching purposes, not only would the patients themselves receive excellent care, but sufficient clinical material would be available to give every graduate in medicine such obstetrical training as would make him a safe and efficient practitioner.

In the larger cities, therefore, maternity hospitals and maternity dispensaries, properly co-ordinated, well equipped and efficiently conducted, offer the sane and logical solution of the midwife problem. In the smaller cities and towns, the problem is somewhat more difficult, but even there it can be very largely handled by utilizing, as maternity dispensary stations, the many small hospitals which are being established so rapidly all over the country. By increasing the annual hospital budget to include such dispensary service, all patients unable to pay physicians, including also the vast majority of midwife cases, could be provided for at a very reasonable cost per patient.

In this way the pupil nurses in such hospitals could be given the training in obstetrical nursing which is now so generally required for the registration of graduate nurses, while the medical service could be very largely supplied by recent graduates in medicine serving as internes in such hospitals, and thereby acquiring, under proper supervision, invaluable experience in operative obstetrics. In the rural and other districts where there are no hospitals, and where there will always exist a lack of medical practitioners, the midwife must continue her work—”doubly dangerous”—because of the scarcity of physicians—unless the State places a higher value than heretofore upon human life and health and comes to the rescue. Upon this point I am in entire agreement with Professor Pritchett, of the Carnegie Foundation, in saying that “A sanitary service, subsidized by the State, will alone render efficient relief in backward districts without demoralizing the profession.”

In attempting to secure certain data with regard to midwives in several of the large cities I have been much disappointed. In Boston, for example, with 18,000 births reported last year, it is not known how many midwives there are, nor how many cases are delivered by them, although birth registration is compulsory. As Boston has a much smaller percentage of foreign-born population than Pittsburgh, it would seem fair, on the basis of Pittsburgh statistics, to estimate that the number of cases cared for in Boston by midwives and dispensaries combined would not exceed 30 per cent. As the dispensaries care for about 19 per cent, the midwives probably deliver not over 11 per cent, or 1,980 cases.

In New York City, according to Dr. Baker, 51,996 births, or 40 per cent of the total number in 1911, were in the hands of some 1,300 midwives. In Philadelphia in 1911, the estimated number of births was 44,000, and the actual number registered was 40,066, of which latter number 21.09 per cent, or 8,450, were delivered by 194 midwives. In Baltimore in 1911, there were but 9,283 reported births, showing very incomplete returns. On the basis of United States Census Reports, the annual birth rate for Baltimore should be about 17,000, and if the midwives deliver 50 per cent of this number, they care for some 8,500 cases. The number of registered midwives in Baltimore is 162.

There were 15,422 reported births in Pittsburgh in 1911, of which 4,864, or 31.53 per cent, were delivered by 150 midwives. Of 12,839 births reported in Cleveland from July 1, 1911, to July 1, 1912, 5,127, or 40 per cent, were in the hands of 266 midwives.
 In Chicago registration is not compulsory, so that complete statistics are not available. Dr. Henry G. Ohls, who has gone over the records of all births reported between January 1 and July 1, 1912, gives the first reliable birth statistics as far as they go. He finds in the total of 19,939 births reported during the six months, that 43.55 per cent, or 8,445, were in the hands of an unknown number of midwives. Dr. Ohls estimates the number of births in Chicago for 1912 to be 57,438. On the basis of his statistics 50 per cent, or 28,719, ought to be a fair estimate of the number of cases delivered by midwives.

On the basis of the number of students graduating annually (1911-1912) from the combined medical schools in Boston, New York, Philadelphia, Baltimore, Pittsburgh, Cleveland and Chicago, it is interesting to see to what extent the midwife cases in these cities could be handled by students alone.

In the data given it would appear that in some instances at least, not all of the cases credited to undergraduate students were actually delivered by them, since many of the deliveries were most probably demonstration cases, observed collectively by a number of students while the actual delivery was being conducted by one of their number under supervision. Then, too, in certain cities large numbers of cases are delivered by graduate physicians doing post-graduate work, and their cases are also included among those credited to undergraduate students. These facts doubtless account to some extent at least, for the great difference in the number of cases reported as delivered by students in the different cities, and must be taken into consideration in interpreting the following figures. In this study it is estimated that if midwives did not exist, at least 25 per cent of the cases now under their care could afford to, and would, employ physicians:

1. Boston: Number of students, 190; cases delivered by students in out-patient departments, 3,500 (19 per cent); midwife cases, 1,980 (11 per cent). Cases credited to each student 18, and 10 additional to handle the midwife cases, or a total of 28 cases per student.
2. Philadelphia: Number of students, 437; cases delivered by students in out-patient departments, 2,566; midwife cases (less 25 per cent), 6,338. Cases credited to each student 6, and 15 additional to handle the midwife cases, or a total of 21 cases per student.
3. Baltimore: Number of students, 334; cases delivered by students in out-patient departments, 1,746; midwife cases (less 25 per cent), 6,375. Cases credited to each student 5, and 19 additional to handle the midwife cases, or a total of 24 cases per student.
4. Pittsburgh: Number of students, 66; cases delivered by students in the hospital and dispensary, 264; midwife cases (less 25 per cent), 3,648. Cases credited to each student 4, and 55 additional to care for the midwife cases, or a total of 59 cases per student.
5. Cleveland: Number of students, 66; cases delivered by students in out-patient departments, 605; midwife cases (less 25 per cent), 3,845. Cases credited to each student 9, and 58 additional to care for the midwife cases, or a total of 67 cases per student.
6. Chicago: Number of students, 608; cases delivered by students in out-patient departments, 1,927; midwife cases (less 25 per cent), 21,540. Cases credited to each student 3, and 35 additional to handle the midwife cases, or a total of 38 cases per student.
7. New York City: Number of students, 325; cases delivered by students, 3,780; midwife cases (less 25 per cent), 38,997. Cases credited to each student 12, and 120 additional to handle the midwife cases, or a total of 132 cases per student.

If the students delivered 50 cases each, or a total of 16,250, there would still remain 26,527 cases to be cared for, so that in New York City at least it would seem that the midwives must do a large part of the work for some time to come, unless the City or State does a considerable part of the work through dispensaries, employing physicians and nurses on salaries. At the same time this would not be so much of an undertaking as it at first appears, since fully 50 per cent of the 38,997 midwife cases could pay to dispensaries as they now pay to midwives—$10 each—and the remainder could pay at least $5 each, the minimum midwife fee in New York City. If the midwives were eliminated in New York City, all their cases could be handled through maternity dispensaries for an additional expenditure of not over $100,000 a year, provided such dispensaries received as much in fees as the midwives now do.

Your committee has asked me to tell also of the plan which we have adopted for the solution of the midwife question in Pittsburgh, and with this I shall conclude my paper.

You will perhaps best appreciate what the Pittsburgh plan is when I tell you that it is, in its development, the concrete expression of the views set forth in this paper. If the recommendations which have been made appear to you visionary and impracticable, you will want to remember that a number of them are already in operation in Pittsburgh, and are working out beautifully, and that we fully expect to carry out the entire scheme within the next half dozen years.

Some three and a half millions of dollars are available for the building, equipment and endowment of a woman’s hospital, to be built in Pittsburg during the coming year; and $50,000 have already been subscribed, from an entirely different source, for the maintenance of a maternity dispensary which was opened some six months ago.

The hospital, which is the first of its kind to be established in this country, has been modeled largely after the well-known “Frauenkliniks” of Germany, and will, therefore, care for both obstetrical and gynecological cases. Abraham Flexner, in his “Medical Education in Europe,” expresses exactly the point of view which we have taken for years, and which now finds its expression in the new Magee Hospital. He says, in speaking of the German clinics for women, that “the women’s clinic combines obstetrical and gynecological wards. Separation into two specialties tends to make a midwife of the obstetrician and an abdominal surgeon of the gynecologist, to the neglect of the fundamental pathological and physiological problems in both cases. Consolidation avoids the necessity of drawing arbitrary lines by way of making two specialties where nature has made but one; for obstetrics and gynecology have a single physiological and anatomical point of departure, namely, the child-bearing function.”

The new hospital will have accommodations for 125 adult patients in the wards and 25 private rooms. It is peculiarly well adapted for teaching purposes, having an operating and teaching amphitheater; a number of examining rooms, delivery rooms and recovery rooms; research laboratories, a medical library, museum and the necessary offices and other rooms for the medical director and his assistants. There are also rooms for photography, X-ray and hydro-therapeutic departments, and an isolation department for infected cases, with the necessary operating and sterilizing rooms. In the private pavilion there is a private gynecological operating room, several private delivery and recovery rooms, a cystoscopy room, etc. The institution will be erected in the center of a ten-acre plot of ground, and will be surrounded by a number of separated and isolated gardens for private patients, ward patients, nurses, physicians, etc.

The medical director of the hospital is also Professor of Obstetrics in the University of Pittsburgh. He resides with his family on the hospital grounds, is paid a salary sufficiently large to make him independent of private practice, and to enable him to devote all his time to the work of the hospital, to research and teaching. All fees received from private patients go into the hospital treasury.
 The Pittsburgh Maternity Dispensary, within two blocks of the Magee Hospital, is closely affiliated with the hospital, having the same directing head. It is located in two large houses of twelve rooms each, and having dormitory accommodations for a dozen physicians and students, as many nurses and social workers, in addition to the dispensary rooms proper. The present staff of workers consists of a social worker, two graduate physicians and three graduate nurses, all on salaries and devoting their entire time to the work of the dispensary; also a number of medical students. The number of workers will be increased as the growth of the work demands it.

The present hospital, housed in temporary quarters, will care for some 350 cases of labor during the present year, and we expect to care for as many more cases in the dispensary during the first year of its existence, or a total of 700 cases, all available for teaching purposes. Our senior medical students, 45 in number, will, during the present year, witness at least fifteen deliveries each, of which number each student will personally deliver six cases under constant supervision and instruction, three in the hospital and three in the dispensary.

The work in Pittsburgh is young, but the outlook is most promising, and we feel that we have in the combination of hospital and dispensary, both teaching institutions, the solution of the midwife problem. And what can be done in Pittsburgh can be done in every other large city in the country. The creation of obstetric charities, such as I have attempted to describe, and the education of the people will in time make the midwife unnecessary and her elimination inevitable.

American Association for Study and Prevention of Infant Mortality
Transactions of the Third Annual Meeting
Cleveland, Ohio October, 2-5, 1912
pages 222-237