HAS THE TRAINED AND SUPERVISED MIDWIFE MADE GOOD? ~ 1910 (part 1 of 3)
American Association for Study and Prevention of Infant Mortality Transactions of the First Annual Meeting – Johns Hopkins University, Baltimore, November 9-11, 1910; pp. 199-213
By ARTHUR BREWSTER EMMONS, 2nd, M. D., Boston, Mass., and JAMES LINCOLN HUNTINGTON, M. D., Boston, Mass.
Your Committee has asked of us to answer three questions. Has the trained and supervised midwife made good? Shall midwives be licensed? and Shall midwives be abolished? We have endeavored to follow closely the Committee’s wording and have divided the paper into three parts, each part answering one of these questions. In doing so, we may be guilty of some repetition, but we feel that to be unavoidable and justifiable under the existing conditions. We hope to show you in the following pages that the midwife never has and never can make good until she becomes a practising 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 and a system substituted whereby the mothers of the future shall receive in their hours of greatest need the attention of men and women thoroughly grounded in obstetrics.
Part 1
Has the trained and supervised midwife made good?
As England is in many ways our nearest neighbor, it is of especial interest for us to see how the situation in England answers our question—to see if the trained and supervised English midwife has made good. And first let us turn back the pages of history.
Four centuries ago the midwives together with the physicians and surgeons were licensed by the bishops. The practice was continued down to the middle of the eighteenth century when the College of Physicians of London assumed this responsibility. Some ninety years ago they ceased this practice and from then until 1902, the midwives in England were for the most part untrained and absolutely without regulation.
And yet we have plenty of evidence that they were very active and that most of the obstetrical cases, except among the well-to-do, were conducted by them. We are most of us familiar with the famous picture of the London midwife as sketched by Charles Dickens in the pages of Martin Chuzzlewit —the squalid, drunken Sairey Gamp! To be sure there were always a few trained midwives, the graduates of leading lying-in hospitals. These seem to have become more numerous and were well organized several years before the opening of the present century.
During the closing decades of the last century, every few years found a bill before Parliament for the licensing and regulation of the midwife. These bills were regularly crushed, usually by medical advice. In spite of these defeats the promoters were steadily gaining in strength and influence while the opposition was careless and divided as to the grounds on which the opposition was based. The opposition was the British Medical Society with the exception of the obstetricians who for the most part were in favor of the bill. There was no counterplan or substitute proposed.
Many of the physicians were undoubtedly influenced by the highest motives, but there can be no doubt that more were opposed to the Midwife Bill because they feared for loss of practice. Authorities vary in the strength of the medical opposition to the bill and figures from 70 to 95 per cent of all the physicians of England are quoted. The supporters of the bill were the Obstetricians, Women’s National Liberal Association, Women’s Industrial Council, Women’s Liberal Federations, The Incorporated Midwives’ Institute and representatives of the Body of Coroners.
In 1900 the measure brought forward by these combined forces was only defeated by a rather determined effort on the part of the British Medical Society and with the opening of the next Parliament the battle was on again fiercer than ever. In spite of a campaign carried on by the medical press the Midwife Bill was made a law on the 30th day of July, 1902. Reduced to simplest terms this law prohibits any woman from using the name of midwife or its equivalent, or to habitually and for gain attend women in childbirth unless certified to do so by a Central Board. Violations of this law to be punished by fine or suspension from practice or both.
All authority is in the hands of the Central Midwives’ Board, composed of nine persons, four to be medical practitioners appointed by medical bodies of recognized standing. Of the other five, one at least must be a woman. This Board was to act under the approval of the Privy Council and after consultation with the General Medical Council. The most essential requirements for the midwife as laid down by this Board are: ability on the part of the candidate to make the obstetrical examination, external and internal; the delivery of 20 lying-in women under competent supervision; and the following of an equal number during ten days after labor. The candidate must also have attended a sufficient course of instruction of not less than three months, and have passed a satisfactory examination. Let us try and see how the law has worked out.
The English midwife is today, for the most part, trained in any one of the leading lying-in hospitals in England, instructed by members of the staff. There are at the present time 31,625 midwives on the roll of the Central Midwives Board, but probably not more than half this number are in actual practice. Certainly in many places they are working in harmony with the medical men and are saving him from a class of patients that he found irksome and unsatisfactory.
There can be no doubt but that the Midwife Bill in operation has improved the situation in England—it has substituted a cleanly and fairly intelligent midwife for the dirty untrained midwife and the utterly careless practitioner. But in passing judgment on the system or taking it for comparison we must remember that the system of midwife attendance always flourished in England—the passage of the Midwife Bill in England did not institute a new system, but attempted to correct the abuse of the then existing system.
Obstetrics in England has not been on the same plane as that existing in America for the past hundred years. We feel that in England today the situation, while improved, is far from being ideal. We feel that in a country where the midwife system of obstetrics is adopted the community as a whole loses, because this form of practitioner is a make-shift admittedly incapable of coping with the abnormalities of pregnancy, labor and the puerperium. The more midwives there are just so much the worse for the community at large, which is thus being supplied by what at best can only be second-class service. Let us now turn to the Continent of Europe to see how the question can be answered there.
In practically the whole of Europe obstetrics has always been conducted by midwives and the system of training and regulation is much the same in all these countries. Certainly the differences between the midwife in Italy, France, Austria and Germany are very slight indeed. As we have had opportunity to study thoroughly the question in Germany, let us take up the situation there in detail, and see the exact position of the German midwife. We feel that a study of her position will show not only the breadth and thoroughness of her training before she is allowed to assume definite responsibility, but also the complicated and complete supervision regarded as essential according to German ideals. Such a study, we feel, will show us what preparations we must be ready and able to make should we decide to adopt a system with the midwife as the solution of our present condition, and also what results we may fairly expect to obtain from such a system.
In Germany practically all normal obstetrics both in and out of Kliniks is conducted by the midwives—though to be sure, an increasing number of persons are by the process of education and cultivation appealing to the physician for at least his supervision at such a trying time. In Germany all classes are represented in the schools of midwifery, from the professor’s daughter to the simplest peasant girl. We must realize that Germany has been training midwives for generations, to understand her hold upon the general public. The trained midwife followed as naturally in the course of development as the trained physician, and we find with the knowledge of the necessity for clean obstetrics, stringent laws have been passed for her education and regulation.
The German midwife of today is trained in the Government Kliniks by university professors who are salaried by the State, often the same professors as those who are responsible for the training of the medical students. In most cases the midwife’s course is six months, all of which time she lives in the hospital where she is trained. Her textbook is issued by the Government and constantly revised so as to be up to date. This she must know almost by heart from cover to cover. This book treats anatomy, including the entire skeleton; the nervous, alimentary and circulatory systems as well as the genitourinary tract. There is also considerable physiology and bacteriology as well as normal and pathological obstetrics.
Besides this there is a statement of her legal status. This book is supplemented by lectures and explained by recitations occupying in all about twelve hours a week throughout the course. She also has thorough drill in the principles of diagnosis by means of abdominal palpation, auscultation, pelvimetry and vaginal examination. She has almost daily drill in the “vaginal touch” by means of the manikin and the fetal cadaver. She is taught the most essential tests for examination of the urine. She is required to make vaginal examinations and to deliver a certain number of cases in the confinement wards under the direction of the resident physician and graduate midwives. Here also she is taught, as far as is possible in the limited time of her instruction, the principles of aseptic technic.
At the conclusion of the course the midwife must pass a rigid examination both oral and written on the subjects she has pursued. Besides answering questions for some 15 minutes, the candidate must demonstrate her knowledge by making a diagnosis of presentation and position in the manikin, outlining her methods of procedure in the given case. As we were present at such an examination we can definitely state that it is a thorough and severe test of the candidate’s knowledge of the subject—it is one that the average graduate of an American medical school would have difficulty in passing with distinction.
Now let us turn to the midwife in practice and see what her position is. She is constantly under the supervision of a physician in the Government service whose duties are in a measure the same as our medical examiner’s plus many of those of a Board of Health officer. To this officer the midwife must report before she enters upon her practice in the given locality; he examines her credentials and establishes her in practice and so long as she remains in his jurisdiction her work is constantly subjected to his supervision.
To him she must report immediately all still births and deaths, all cases of puerperal fever and ophthalmia neonatorum. Her home, her equipment, her clothing and her person must always be ready for his inspection. She may lose her right to practice if her home is dirty or if she is caring for an obstetrical case under her own roof. The contents of her bag and her case book are outlined by law. She is required to wear clean and washable gowns when in attendance on cases. Her hands must be clean and the skin and nails in good condition at all times. She must report to this officer any septic lesion or ulcer on any part of her body. Violations of these rules will lead to swift punishment—fine or imprisonment, or both.
The midwife must also report immediately to some local physician any symptoms suggesting eclampsia or miscarriage or any serious complication of pregnancy. She must be equally prompt in reporting any case of antepartum hemorrhage, contracted pelvis, or abnormal presentation—and this includes a breech presentation. Should the second stage last more than 2 hours without progress; the pulse or temperature rise above the limit considered not normal in obstetrics; the fetal heart rise above 180 or fall below 110; the placenta remain in the uterus too long after delivery; the uterus fail to contract and continue to bleed; or the perineum rupture during delivery, the midwife in each and every instance must notify a physician in writing of the exact condition or communicate with him personally over the telephone.
And the physician must in such a case respond at once, unless actually engaged on a case that requires his immediate attention, when he must so communicate to the midwife or the messenger. Should the midwife or the physician fail to follow these laws, they are subject to punishment. In case an emergency arises where time is of utmost importance and her powers are limited by law from doing what she knows to be necessary, after notifying the physician or even before if the emergency demands, it shall be her duty to do whatever seems necessary for her to perform—save only version and instrumental obstetrics—but in each and every instance she must communicate as soon as possible with the medical examiner, telling him the exact circumstances and abiding by his decision as to whether or not her action was justified.
This gives a rough picture of the duties and responsibility of the German midwife and the careful supervision exercised over her. Added to all this she must return every few years for re-examination after a few days’ residence in the Klinik so that she will keep up to date. But let us see if the midwife in practice lives up to all this. In the first place, one observing the work of the midwife in the confinement ward is struck by her lack of what is known as the aseptic conscience; that is the knowledge that one is, or is not, surgically clean. After faithfully scrubbing her hands for the allotted 15 minutes, the midwife will unconsciously touch something outside of the sterile field and continue as if surgically clean. This the writers have often observed.
Of course, there are exceptional pupil-midwives who do not fall into this error and these are usually the ones who have graduated as nurses before beginning the training in the midwife school. But one cannot help feeling that if these breaks in aseptic technic are made in the hospital where the pupil is working under vigilant instructors, how much more apt she will be to fall into unsurgical habits while working in a peasant’s home. This carelessness is even more marked in the older midwives when they return for instruction.
Obstetricians in Germany are far from satisfied with the present system. They admit it is illogical, but it is so firmly established it seems impossible to make a change. Puerperal fever is much more prevalent than should be. Prof. Bumm states in his text-book on obstetrics that in one year out of 2,000,000 births 5,000 deaths from puerperal fever were reported and, of course, many more failed to be accurately reported. A year or so ago a Berlin physician prominent in gynecology wrote to a committee of the American Medical Association asking for information in regard to the number of deaths from puerperal fever in this country, as he understood that we were without midwives.
The answer was made that not only were we without vital statistics of any value, but that we were in many States overrun with midwives. The Department of Medical Economics of the Journal of the A. M. A., referring to this correspondence, add, “Midwifery is not as well regulated in this country as in Europe, and yet the harm done is probably less, since midwives are not so numerous.” Thus we have in Germany a system of training and regulation of the midwife so complete as to be almost ideal, a system of seemingly perfect harmony between the midwife and physician.
But let us look a little closer at this very point and we shall see why the thoughtful German obstetrician is dissatisfied with the present scheme. There are rules for harmony laid down in the statute book, but the midwife is not well paid, and it is profitable for her to deliver the case if possible without calling in the physician, so she is all too apt to let the case go as long as seems safe without her falling into the clutches of the law. Then too the physician when called to such a case is far from being as careful as if it had been his case from the beginning, for it is so easy to say that had he been called earlier all would have been well. The obstetrician cannot give his best care to a case under such circumstances.
Then there is the other great defect in the system that unlike any other branch of medicine there are two standards of skill offered to the public. Thus we see instead of the perfect harmony a waste of precious minutes because of greed and ignorance; divided responsibility because of the nature of the system and also because of jealousy; and two standards of skill where science and logic demand but one. And so even on the Continent where ages have given the midwife an established position, yet the leading obstetricians will tell you that the midwife has not made good. It is almost absurd to ask the question “Has the trained and supervised midwife made good in America?”
We have never had a system of training of midwives worthy of the name, neither have we had any successful method of supervision, with the single exception of New York City, details of which have been presented by another speaker. The fact is, the midwife is not a native product of America. She has always been here, but only incidentally and only because America has always been receiving generous importations of immigrants from the continent of Europe. We have never adopted in any State a system of obstetrics with the midwife as the working agent.
It has almost been a rule that the more immigrants arriving in a locality, the more midwives would flourish there. But as soon as the immigrant is assimilated and becomes a part of our civilization, then the midwife no longer is a feature in his home. We also know that the finely trained midwife who comes with her diploma and her sterilizer from the schools of the Old World, finding no use for either of these articles, forgets that she ever possessed them and becomes to all intents and purposes an untrained midwife. There are exceptions, but in our experience they are few.
No! We in America are not willing to trouble ourselves with the enforcement of the details of a code of laws rigid enough to make a midwife attend to her duties and practice within her narrow boundaries as laid down for her in the Old World. We can safely and truthfully say that the midwife has not made good in America, and we see no possibility of any system whereby even by a lax use of the phrase we could predict for her that she would make good!
Shall Midwives Be Licensed? Continue on to part 2
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American Association for Study and Prevention of Infant Mortality Transactions of the First Annual Meeting Johns Hopkins University, Baltimore, November 9-11, 1910 pp. 199-213
