~ 1910 (part 2 of 3)

by faithgibson on September 23, 2012

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.,

Part 2

Shall Midwives Be Licensed?

First let us see the minimum amount of care which in the light of modern medicine it is fair, right and humane to offer the impecunious mother. Then let us consider whether the midwife can be expected to reach and maintain such a standard and if so at what cost of money, time and effort.
 We suggest the following as a brief and fair summary of the minimum training which may be ordinarily demanded today of those who are to assume the care of the expectant mother.

Ability to make the preliminary obstetrical examination; and this includes knowledge of the use of the pelvimeter and ability to auscult the foetal heart. In other words, to make a diagnosis of pregnancy and to determine whether the bony development of the mother is normal enough to make labor a safe procedure.

Knowledge of how to examine the urine of the pregnant woman so as to receive the first warnings of threatened eclampsia, the most serious complication of an otherwise normal pregnancy.

Ability to conduct a normal case of labor. And this is first of all asepsis—not only the theory but the trained instinct of surgical cleanliness and how it can be maintained—thus tending to prevent puerperal fever, the great cause of death to the mothers of the past and now rarely seen where asepsis is practiced.

Ability to make the internal examination, thus being able to diagnose many of the serious complications of labor in time to take the proper steps to save both mother and child. A knowledge of anesthetics, now pretty generally accepted as advisable in all cases of labor; humane and useful agents, dangerous in inexperienced hands, but frequently a necessity.

Ability to properly care for the breasts, to supervise the nursing and proper hygiene of the infant.
 In the light of modern medicine, we know these are the simplest requirements and the right of every mother in civilized communities.

Much more than this is to be expected of the obstetrician. But as we read through this list, how many teachers of obstetrics, judging from their experience in teaching students and nurses would care to undertake the training of the midwife as we have seen her in the city slums? How many would care to feel the responsibility for her work in practice? But if the teachers of medicine of experience cannot accept this responsibility, what are we to do? The obvious answer is to keep training the midwife until she has reached a sufficient degree of efficiency. Can this be done in America? We feel that it is impossible.

The story of medical education in this country is not the story of complete success. We have made ourselves the jest of scientists throughout the world by our lack of uniform standard. Until we have solved the problem of how not to produce incompetent physicians, let us not complicate the problem by attempting to properly train a new class of practitioners. The opportunities for clinical instruction in our large cities are all too few to properly train our nurses and our doctors; how can we for an instant consider the training of the midwife as well?

The midwife is called in question today not because of the popular demand for her services, but because investigation into disease and death has revealed her working in her filthy surroundings and has shocked the medical and lay public into action. Let us who are pledged to consider the welfare of the infant see that this action is not misdirected.

The midwife is willing to undertake maternity work that no well-trained obstetrical nurse would think of attempting, because, in the first place, she is ignorant of the situation—she has the over-confidence of half knowledge. She is usually unprincipled, anxious only for the fee, and callous of the feelings and welfare of her patients. She looks upon her work as a legitimate form of livelihood, not as an ennobling profession.

But let us look at the picture from another standpoint, and consider that the midwife is licensed. The question of regulation is one that goes hand in hand with the licensing power. To license the midwife and then neglect to regulate her has produced the results in Illinois, Maryland, and New York which have started the discussion of the whole midwife question. We can take it for granted that all will agree that the licensed midwife must be regulated. How is that to be done? The obvious answer is by legislation. But we know by experience that in America legislation without public sentiment behind the law is absolutely futile.

Let us suppose, however, for the sake of argument, that the impossible has been accomplished, that we have an aroused community and laws as stringent as those of Germany for the regulation of the midwife, we must realize that it means in each community inspectors trained in medicine and paid by the Government to give their exclusive time to supervising the midwife, and not only that, but a medical profession forced by law to respond to the call of the midwife in trouble.

Do you honestly think for one moment that we could accomplish this in America?
 But let us grant all this as possible and consider whether it would be worth while. By gradual steps we should have evolved a double system of obstetrics enforced by law through well-paid medical officers and backed by popular sentiment— would it be a success? We answer, No! It would be a double system, two standards of excellence which can never work together, and yet based on the assumption that they are interlocking parts of the same machine.

Why should we adopt in obstetrics this double system? Certainly there can be no more important branch of medicine than this and yet with the possible exception of ophthalmology, we have no attempt in any field of medicine to adopt a double system of practice. Why should we not oppose the midwife on the same ground that we oppose the optometrist?

Both because of their limited training are incompetent to bear the responsibilities they attempt to assume. And whereas the worst the optometrist is likely to do is to subject his victim to financial loss and injure his eyesight, the midwife can, by her ignorance alone, cost the community the loss of two lives and not only escape any punishment but be rewarded by a fee for her activities. And when we picture the unnecessary and enduring sorrow her act has caused we should think well before we put such power in her hands.

Continue to Part 3 ~ Shall the Midwife Be Abolished?

1. Boston Med. Library P. Vol. LVIII. No. 4
2. Boston Med. & Surg. Jour. Vol. CIX. p. 799 & p. 805
3. Boston Med. & Surg. Jour. Vol. CLXIII. p. 90
4. Boston Med. & Surg. Jour. Vol. CLXIV, p. 251
5. Brit. Med. Jour. 1891. II. p. 94
6. Brit. Med. Jour. 1892. Feb. 22. p. 477
7. Bull. Med. & Chir. Fac. of Maryland. Vol. II. No. 7. pp. 131 and 151. Jan. 1910
8. Bumm, E., “Grunduis Zam Studium der Geburtshilfe,” Weisbaden, 1908, p. 789.
9. Jour. Am. Med. Asso. Vol. XLVIII. p. 712. Feb. 23. 1907
10. Jour. Am. Med. Asso. Vol. L, p. 1346. April 25. 1908
11. Jour. Am. Med. Asso. Vol. LII. p. 2009
12. Jour. Am. Med. Asso. Vol. LIII. p. 1040, Sept. 25. 1909
13. Jour. Am. Med. Asso. Vol. LIV. p. 409. Feb. 5. 1910
14. Jour. Am. Med. Asso. Vol. LIV, London letter. April 23. 1910
15. Jour. Mich. Med. Soc. Vol. VII. p. 5. May. 1908
16. London Lancet Nov. 9, 1901, p. 1301
17. London Lancet Feb. 22. 1902. pp. 532 and 542
18. London Lancet, March 8, 1902, p. 688
19. London Lancet May 3. 1902. p. 1278
20. London Lancet June 21. 1902, p. 1808
21. London Lancet Aug. 22, 1903, p. 555
22. London Lancet Jan. 9, 1904, p. 113
23. London Lancet Vol. I, 1904, p. 356
24. Mass. Board of Registration In Medicine, 16th Annual Report, Pub. Doc. No. 56, Dec. 31. 1909, pp. 14, 18 and 23
 25. New York City Board of Health “Rules for Midwives.”
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