HAS THE TRAINED AND SUPERVISED MIDWIFE MADE GOOD? ~ 1910 (part 3 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.
Shall the Midwife Be Abolished?
We feel that this question should be answered emphatically in the affirmative, when and wherever it is possible. We feel that in this position we are but keeping step with progress in preventive medicine and following out the logical solution of what is best and safest. But we go further and feel certain that the untrained and unscrupulous physician should be put in the same class with the midwife and laid aside as soon as is possible by guarded legislation and education of the public conscience. We are not satisfied with generalities, as we feel that sweeping condemnation is not enough to bring about a change of any value. Let us show definitely and in detail just exactly how these much-needed reforms can be made.
If our remarks seem didactic in dealing with conditions outside of our own State, among surroundings we know little of—pardon us, we mean no possible offence. We are dealing with a problem about which it is next to impossible to know, except by first hand, all the details and facts.
To begin with, let us show you the condition in Massachusetts and what we feel to be of vital importance in our own State. By the Medical Practice Law, midwives are excluded from the practice of obstetrics. They have been found violating the law and in two or three instances have been caught and convicted and have paid fines for practicing medicine without a license.
In spite of this, some hundred and fifty women are practicing as midwives. These are for the most part, poorly trained and incompetent women. Their stronghold is in the manufacturing cities of about 100,000 population, largely composed of immigrants. There are a few midwives in Boston, but their practice is small. We feel that in Massachusetts, under such favorable circumstances, the State and local medical societies should see to it that the law plainly written on the statute books be enforced, and at the same time by dispensary systems provide for the immigrant population.
In States where the midwife is practically unknown, it should be seen to that the Medical Practice Law excludes the possibility of midwives practicing within the limits of the State. In States where the midwives are not forbidden by law to practice and are numerous, a well organized license and regulation system should control those in practice. Outline for them the minimum standard for their cases and enforce at least this standard by taking away the licenses of those who violate the law. Renew the old licenses every year and issue no new ones. Thus the midwives will gradually be excluded from practice by their own incompetency and by the lapse of time.
At the same time earnest endeavor must be made to provide competent obstetric care for the impecunious. In States now overrun with midwives the task is harder, but we think neither discouraging nor impossible. Have a thorough system of examination given in German, French and Italian, and enough midwives will be able to pass such an examination to care for those who will only be satisfied with the attention of the midwife. Then by inspection keep these women up to the highest standard they are capable of pursuing. Only allow those to practice who can pass the examination, and have the license to practice an annual affair based on the record for the previous year. Then by gradually raising the standard and providing dispensary care for all who will apply, the problem in a few years would simplify itself.
Of course, this is with the understanding that the schools for midwives which have been proven on inspection to be merely diploma mills, be abolished, and the midwives drawn to supply the demand largely from the graduates of the continental schools—institutions with which we can never hope to compete.
[Two successful systems for providing obstetrical care for the poor of our cities]
We wish to present to you in detail two successful systems for providing obstetrical care for the poor of our cities. We offer these two not as any better than other institutions elsewhere in the country, but merely to present the working plan of a system that can be applied with modification to any surroundings. We first wish to show you the working of the Boston Lying-in Hospital, which last year cared for the confinement of 829 women in its wards and 2,007 women in their own homes. The patients are supervised in a pregnancy clinic from the date of application as soon as the condition is diagnosed, until they fall in labor. The pregnancy clinic is supervised by a corps of obstetricians who are assisted by the house officers and nurses in carrying out the work.
When the patient falls in labor she is either delivered in the wards of the hospital or in her own home, depending on the nature of her case, her place of residence, her inclination and, to a lesser degree, her ability to pay. If she is confined at her home she is attended by a student externe. These student externes are for the most part undergraduates of the Harvard Medical School or post graduate students from other institutions. They live at the hospital or in the branch of the hospital, which is located in another congested section of Boston, for a period of two weeks; their rooms and the care of the same being provided by the hospital management. These externes are constantly under the control of two resident physicians who give their exclusive time to this work; these resident physicians being in turn under a staff of older physicians who are constantly on call for any serious emergency.
How successfully this has worked out can best be shown by the statement that during the past year these 2,007 cases were delivered with no maternal mortality. But another encouraging and very practical feature has been that these 2,007 patients voluntarily contributed to the support of the hospital the sum of $2,571.00 or on the average $1.28 contributed by each patient and the total expenses of the out-patient department were $1,763.18, leaving a net gain of $807.82.
Certainly this institution can not be accused of pauperizing the community. We feel that some such scheme as this can be carried out in every medical center where medical schools are near at hand. In the smaller cities away from medical schools the young doctor, the visiting nurses’ association and a few beds in a hospital give a very excellent substitute for this more elaborate system.
Let us look at such an institution at work. The City of Manchester, New Hampshire, has 70,000 inhabitants, including a large foreign population. In a central location is the building of the City Mission, a non-sectarian institution which is under the management of the Missionary Board of Control in which all the churches of Manchester are represented—up till now, however, the Roman Catholics have not entered into co-operation. In this building are rooms given over to the use of the District Nurse Association, which is an important factor in this scheme. The active executive is the city missionary, a very able woman. Application is made to the City Mission by those unable to employ a physician. The home is visited, the need determined and the district nurse is called in.
About 150 obstetric cases are cared for annually. These are attended during confinement by the young physicians of the city who are members of the local medical society and have signified their desire to be on call for obstetrical cases among the poor for two months of each year. Thus the young practitioner gains experience and may even acquire patients for his future practice. There is also a city physician who is required to take care of paupers. But few self-respecting poor are willing to sign papers to obtain his services. For those cases which present complications which can not be properly dealt with in the patient’s own home, there are three beds in the local hospital at the disposal of the City Mission.
We learned that although there were a few midwives in Manchester they had but little practice and only among the newly arrived immigrants who were ignorant of the City Mission and its work. This arrangement has apparently worked out well and there has been no indication of abuse of medical charity. This City Mission is supported by public subscription, including donations from the various mill owners and manufacturers of the town, the various women’s clubs of the churches as well as the generosity of the charitably inclined well-to-do. The city government gives nothing and it is not desired that it should, for it has been found that when the city aids, others cease to feel the obligation and personal interest in the work.
Such a plan it will be seen includes the social workers, the district nurse and the physician. To this is added possible hospital care in critical cases. To this might be added with advantage, where the demand was sufficiently great, a supply woman directory and a list of available wet nurses. This system is efficient, economical and has proven satisfactory by years of service. We see no reason why it cannot be applied with modification in the smaller cities.
Conclusion
The object of this meeting of this section of our National Society we believe to be to fully consider the facts presented concerning midwives in general and the midwife in America in particular. From this consideration we should draw conclusions and lay out a policy national in scope. Were such a policy accepted by the several States, each separate community must consider local conditions, opportunities and resources, and apply the principles of such a policy as far as is possible to meet these given conditions. We all should return to our separate homes determined to carry out the plan which will finally give our community the best system of obstetric care which is practicable under the circumstances.
So let us be far-sighted in our plans and produce a policy nation-wide in scope and yet plastic enough to be shaped to the needs of each and every community. And let it all tend towards that goal for which we must all sooner or later strive, a single standard of obstetrical excellence, at the disposal of all, rich and poor alike. A standard which only takes into consideration the best possible immediate attention for the welfare of “All women in the perils of child-birth.”
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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
