Editor’s Note — needs editing!
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1349440/pdf/amjph00249-0095.pdf
Public Health – Then and Now
AJPH October 1988, Vol. 78, No 10 page 1353
Joseph B. DeLee and the Practice of Preventive Obstetrics
by Judith Walzer Leavitt, PhD
Editorial Comments and Background:
1. Dr. Delee’s impact on childbirth practices in America — ultimately resulting in the complete obstetricalization of maternity care for healthy women — is a key figure in the history of 20th-century maternity care in the US. He advocated for the universal hospitalization of maternity patients and played a critical role in turning normal childbirth into a surgical procedure in the US. His influence on the politicization and widespread elimination of midwifery from 1900 to 1950 was also wrong and unwise.
2. For these reasons, he is very controversial today. Based on such frankly disturbing historical reports, many childbirth activists, especially those who think of themselves as feminists, revile him in unprintable language. I imagine a group chanting voo-doo curses, and with a gleam in their eyes, stick pins in a “Dr DeLee” cuppie doll. But these overwhelmingly negative opinions are unfortunate, as his legacy has a lot value to contribute to us.
3. His body of work is informative in its own right and extremely critical element in fixing many of the problems that he and other influential obstetricians of his era were responsible for causing.
4. His historical textbook — Principles and Practice of Obstetrics — provides contemporary midwives {Editor’s Note — i was on of those midwives!} with many astute observation about normal childbirth and how many rare but serious complications were recognized in an era before the use ultrasound and other modern diagnostic tests.
5. Equally if not more important is understanding what motivated him, which allow the modern reader to also understand why obstetrics in American developed as it did, which is to say, why we have an obstetrical system {Ed Note — & not a maternity system!} that turns healthy women into the patients of a surgical speciality and normal childbirth into a hospital-based surgical procedure.
As someone who has carefully studied his life, his work, his many publications, the record of services provided by the Chicago Maternity Center (also known at times as the Chicago Lying-in Hospital) and two documentary films about him and this era of obstetrical medicine, I assure you that he was a good man AND equally important, he was a product a very difficult period of American history.
This era of our history was made much more difficult than it needed to be by the total rejection of national health care by the AMA, who were obsessively, compulsively and publicly vitriolic in their total rejection of what they called “socialized medicine”. This alone made childbirth in American very different and very much more dangerous than the same era in Sweden (MMR in United States in 1900 was three times greater than Sweden). This dramatically lower rate of morbidity and mortality for childbearing women and newborns was also true for other European countries.
This disparity in medical and maternity services between the US and Europe, and resulting high maternal and infant mortality rate, was not the only problem for childbearing families. The practical ability of medicine to effectively treat the ill and injured between 1895 and 1945 (after discovery of the germ theory, but before the invention of antibiotic drugs), was also dismal. While the great advances in its theoretical knowledge base were exciting and promised much, the medical profession (especially obstetrics) was still many decades away from the practical applications these new and therapeutically-effective theories.
For providers of maternity care, the many inadequacies of early 20th century medicine was combined with rampant class and racial discrimination and a total absence of government social services (no ‘safety net’) for poor working women and immigrant families . Rickets and the badly deformed pelvis, which was only one of its many awful effects) was very common for women living in tenement housing for the very poor, often built in the shadow of huge manufacturing plants that belched smoke and soat ??. There was no vitamin-D triggering sunshine, nor was it a safe place for children to play outdoors.
Underfed and overworked married women experienced forced and frequent childbearing in social climate that did not permit the use of contraception. Without access to prenatal care or preventive forms of medical care, this underclass of women often developed toxemia or suffered undiagnosed kidney, and heart disease in subsequent pregnancies.
This was the population that Dr. Delee served and did so for free or at drastically reduced fees. The maternity care provided by his Chicago Maternity Center/Lying-in Hospital) consisted of state-of-the-art prenatal and postpartum services in the Maxwell Street Dispensary, and a staff of general practitioners (now called ‘family practice physicians’) and nurses personally trained by Dr DeLee. The protocol for CMA was to send teams of three — one graduate MD, a medical student and a nurse — who were equipped to conduct childbirth under aseptic conditions to the homes of what Mother Teresa called “the poorest of the poor”. These families often lived in 5th-floor walk-up tenements under appalling conditions.
As has always been true of midwifery care, they were present in the family’s small, cramped, often dirty and bug-infested apartment for the entire active stages of labor, the birth and for (you guessed it!) 2 hours after the birth. They also performed a newborn exam and instructed the mother about her postpartum care and the family on how to support the new mother and new baby.
Between 1895 and 1974 69,000 planned home births were attended by CMA personnel trained by and responsible to Dr. DeLee, using his “dispensary” (or out-patient) model. And they achieve excellent results with very modest use of resources. The maternal and infant mortality rate for his home-based birth service were consistently lower than of the rest of the city and the nation. In fact, the national MMR did not match those of Dr DeLee’s planned home births until antibiotic drugs were developed and became available in the US in 1945.
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Ignore orphan phrase –> “having promoted many interventions (ex. and routine use of forceps) during the first 25 years of his professional life that he later regretted and spoke out against.”
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In his 1920 paper on the “Prophylactic Use of Forceps” he compared childbirth in humans to salmon reproduction by saying:
”… I have often wondered whether Nature did not deliberately intend women should be used up in the process of reproduction, in a manner analogous to that of salmon, which dies after spawning?”6
This particular comment of his reveals a deep fear about childbirth that reflected his actual experience as a physician in a time and in places and circumstances that indeed did result in bad outcomes and preventable disability and death for far too many new mothers and very often, their newborns as well.
that colored his ideas and influenced his development of what he described as ‘preventive obstetrics’. In our own time, DeLee’s attitudes and invasive procedures that he promoted as part of routine care for healthy women, are seen as still
However, Dr. DeLee was equally
But instead of merely commiserating in this woeful potential, DeLee presented a system that he believed could begin to stem the tide of obstetrical disasters, namely, routinized medical intervention to allow physicians to control the course of labor and to prevent the damage that birth could create.
He believed that labor unaided was pathogenic because experience demonstrated that it adversely affected women’s health, in another famous analogy likening it to a pitchfork driven through the mother’s perineum. This “natural” process, DeLee concluded, in fact put women at great risk for their life and health.
Perhaps laceration, prolapse and all the evils [women in labor are subject to] are, in fact, natural to labor and therefore normal, in the same way as the death of the mother salmon and the death of the male bee in copulation, are natural and normal.
If you adopt this view, I have no ground to stand on, but, if you believe that a woman after delivery should be as healthy, as well, as anatomically perfect as she was before, and that the child should be undamaged, then you will have to agree with me that labor is pathogenic, because experience has proved such ideal results exceedingly rare.’
DeLee proposed that maternal morbidity and mortality could be decreased through regular medical interference. He suggested that specialist obstetricians sedate the parturient with scopolamine when labor started, allow the cervix to dilate, give ether during the second stage, perform an episiotomy, and lift the fetus [out] with forceps. They should then extract the placenta, give ergot to help the uterus contract, and stitch the perineal cut.
The only part of the process that DeLee left to the woman herself was the full dilatation of the cervix, admitting that medicine could not yet provide safe help for that part of the process. He concluded that: “instrumental delivery is safer than prolonged, hard, unassisted labor.”8 DeLee believed his methods would save women from debilitating effects of suferring, preserve the integrity of the pelvic floor, and save babies’ brains from injury.
Of course DeLee did not invent physician interventions during labor and delivery. Ever since they had first been invited into women’s birthing rooms, in this country since the 18th century [i. e. 1700s], physicians have actively participated in the birth process.
Allaying some discomforts with opiates, aiding protracted labors with forceps [editor’s note: historically the very first of these interventions, and then that was seen as the most benign was for physicians to eliminate the need to wait for the natural expulsion of the placenta by physically reaching up though the vagina, inserting the doctor’s hand into the uterus and manually defacing it from the uterine lining and removing the ball of placental tissue, and its attached umbilical cord and amniotic membranes. Unfortunately, in many instances this also introduced the bacteria that caused the fatal infection called “childbed fever” (puerperal sepsis or septicemia)] .… by the middle of the 19th century [1800s], obliterating pain with anesthetics, physician had been more than watchful bystanders in the birth chambers to which they had been called. Walter Channing, and early 19th century Harvard obstetricians, had prescribed that physicians, when called to attending parturient women, “do something,” and most had dutifully followed that advise. [9]
Delete changed the focus of actions from responding to a specific perceived problem to intervening prophylactically and routinely. DeLee did not want to wait until the course of labor indicated women were in trouble and needed interventions; he wanted intreat to prevent any problems from developing by intervention first, by explicitly directing the course of labor and delivery.
Excerpted from p. 1355:
The dilemma debated at the 45th meeting of the American Gynecologist Society in Chicago and May 1920 with such famous American obstetricians as J. Whitridge Williams, John0.Polak of New York, Henry T. Byford of Chicago, and Edward P. Davis of Philadelphia, …. and more generally in the profession was a significant one.
These prominent obstetricians acknowledged that too many women died in childbirth: they agree that the massacre of women could be halted by better medical technique.* All acknowledged that “meddlesome midwifery”, by which was meant the inappropriate and technically mismanaged interference in labor associated with the practice of many doctors, caused significant problem for parturient (giving birth) women. All believed also that labor unattended in many cases proved just as damaging to women: a fetus’s head pounding at the perennial tissue could produce damage just as surely as misused forceps.
It was not intervention itself that worked DeLee’s colleagues; it was intervention without the presence of an indication it was needed. DeLee was looking for preventive techniques to save women before they suffered damage during labor and delivery; his fellow obstetricians felt more comfortable acting to overt a dangerous situation once it presented. They wanted to cure a problem if it developed; DeLee wanted to prevent it from developing.
(*a questionable assumption in light of the Sweden’s dramatically lower MMR at this time in history and their record of drastically reducing maternal and neonatal deaths by passing national legislation in 1881 that legally required both physicians and midwives that provided maternity care to use antiseptic hand-washing techniques and the principles of aseptic when attending childbearing women.
In the early 20th century the maternal mortality rate in the United States was three times higher than Sweden. At that time, American visitors recognized this low MMR as a notable achievement of Swedish maternity care, in which highly competent midwives attend home deliveries.
Between 1861, when the Swedish MMR was very high in and 1900 when it has dropped to a level that was a third of America’s MMR (only 232 per 100,000 in Sweden vs. 700 per 100,000 in the US), the national government of Sweden implemented state provision of formal midwifery training program for student midwives and a national strategy that gave midwives and doctors complementary roles in maternity care, as well as equal involvement in setting public health policy.
That DeLee’s concern for medically-directed prevention was integral to his medical philosophy was strongly evident throughout his career. It represented his complete-if some-what naive faith in the power of medicine, and it also reflected his understanding of the unreliable and dangerous state of obstetrics practiced at the time and the differing needs of [childbearing] women.
Having been raised in an immigrant family that had its share of financial setbacks, DeLee was sensitive to the fact that he lived in a class- and race-divided country, and he believed these divisions could-and should, at least in the short run-affect the ways in which medicine was practiced. In order to understand how his 1920 insistence on prevention as active medicine emerged and to set it within a slightly broader framework, it is necessary to take a brief look at DeLee’s life and career.
Joseph Bolivar DeLee was born in 1869, one of 10 children in a Cold Springs, New York, Jewish immigrant
family.’7 His father, Morris DeLee, a dry goods merchant, did not want his son to become a physician, preferring for him the scholarly life of a rabbi. But Joseph’s mother, Dora Tobias DeLee, described as the pilar of the family, helped
her son realize his medical ambition. Business reverses
removed the family from Cold Springs to Manhattan and
family.’7 His father, Morris DeLee, a dry goods merchant, did not want his son to become a physician, preferring for him the scholarly life of a rabbi. But Joseph’s mother, Dora Tobias DeLee, described as the pilar of the family, helped
her son realize his medical ambition. Business reverses
removed the family from Cold Springs to Manhattan and
ultimately to Chicago, where Joseph’s oldest brother Sol had settled.
As a teenager,Joseph added to the family’s precarious economy by selling doorbells. In 1888 (age19) DeLee entered medical school at Chicago Medical College, later
Northwestern University MedicalSchool. He had the financial help and support of his brother Sol through medical school, internship, and postgraduate study abroad.
While a student, he worked in a Chicago baby farm, where illegitimate children suffered a frightful mortality.
Finally, in 1894, Joseph, aged 25, again with his family’s financial and moral support, set himself up in practice in Chicago.
DeLee’s interest in obstetrics developed from his student experiences at the baby farm, where he had seen many
babies die from cerebral hemorrhages, presumably associated with difficult deliveries. It was fostered in medical school by his obstetrics proffesor, W.W. Jagard, who was known for his respect for his patients. “Regard the information imparted by the patient as sacred,” Jaggard taught.’8 The high maternal and infant mortality then associated with childbirth impressed itself upon DeLee during his training, as did medicine’s potential for overcoming the problems. His immediate ambition-upon returning to Chicago from Europe where he had studied maternity services– was to establish a lying-in hospital and a home-delivery service.
Maternal mortality was, in fact, extremely high in the United States at the turn of the twentieth century. Death claimed one woman for every 154 live births. Sweden’s women, by comparison, suffered one death for every 430 live births. While deaths associated with infectious diseases were beginning their descent-responding in part to the activities of the public health movement and the accomplishments of the new science of bacteriology-maternal mortality {in the US} maintained its nineteenth century rates until the antibiotic era {after 1945}. Much of the mortality was due to postpartum infection, which physicians realized should have declined in relation to medical knowledge about germ transmission. [19] DeLee set his life-time goal to use his medical expertise to stem the tides of preventable maternal mortality.
Under the auspices of Northwestern, DeLee opened a maternity clinic at the South Side Free Dispensary, but it did not thrive. When the medical school did not exhibit enough enthusiasm for the project and the community women were unresponsive to the service, DeLee was forced to look for other sources of support. Aided by the Young Men’s Hebrew Charity Association, some prominent Jewish women, and again by brother Sol, DeLee launched the Chicago Lying-In Hospital and Dispensary in 1895. Occupying four rooms on the ground floor of a Maxwell Street tenement, in the heart of the immigrant community, the clinic opened on a cold February day when DeLee and his sister Gussie awaited the first patients.
For the next 79 years, (that is, until 1974) the Maxwell Street Dispensary (later called the Chicago Maternity Center and physically separated from the Lying-In Hospital) served Chicago’s impoverished pregnant women. It received the support of the Women’s Club of Chicago and various philanthropic organizations; and it maintained an association with Northwestern University Medical School, training its medical students and ultimately those from Iowa and Wisconsin in methods of aseptic home deliveries.20 The facility also trained nurses in obstetric services. DeLee’s name was associated with providing poor women with opportunities for safe, inexpensive home deliveries. He referred to the dispensary as “my first love” years after his own national and international reputation has been established. When the dispensary was threatened by financial troubles, DeLee such his own funds — and usually his family’s as well — into its maintenance.
The Chicago Maternity Center operated on simple principles of maternity care, which DeLee disseminated though-out the profession with his labor and delivery films and his textbooks, articles and lectures. [21] Free prenatal care was available to those women who registered ahead with the Center. Once labor began, a team consisting of a graduate physician, a medical student, and a nurse attended the woman in her home, bringing with them equipment for aseptic technique.They also brought principles of minimal operative interference. Indeed, if physicians on the Maternity Center staff disregarded the procedures-if, for example, they used pituitrin {i.e. now would be the use of Pitocin} before the birth of the baby- they would be dismissed.22
DeLee insisted upon non-interventionist practices in his outpatient service, and he maintained the importance of watchful waiting in home-based obstetrics practices through-out his entire career. In 1916 he decried prevalent meddle-some practices:”Let me urge that we depart not too far from our trust in the natural forces of labor, that we still uphold the policy of ‘watchful expectancy’ or, if you prefer, ‘armed expectancy, ‘ that we remember that the obstetrician’s duty is not to make labor a surgical operation, but to conduct it as a natural function, interfering only when called on by the necessity of preventing undue suffering, or saving fetal or maternal life.” 23
In1940, in one of his last published papers, DeLee based his protest against the use of posterior pituitary {earlier form of the labor inducing or augmentation drug “Pitocin” now used} on similar principles:
“Now why should you want to hurry a normal labor? The woman certainly has plenty of time, and if she takes nine months producing a baby I don’t think she could spend her time in any better way than in devoting a few hours to delivering it. From the woman’s point-of-view there is no hurry. Nobody has ever proved that solution of posterior pituitary has any prophylactic values.’’24 Through-out his medical career, DeLee voiced the value of non-interventionist obstetrics.
The Maxwell Street Dispensary, serving poor women with in their own homes and training physicians in elementary, non-interventionist obstetrics practices, showed a side of DeLee that seems diametrically opposed to the DeLee who advocated prophylactic forceps.
DeLee himself believed all his causes to be of one piece. The single thread that connected all of his obstetric concerns was saving the lives of mothers and babies as they entered into their most dangerous moments during labor and delivery. Specificaly, the desire to prevent maternal and infant mortality and morbidity, coupled with the necessity to lift the status and effectiveness of obstetrics, which he thought necessary to achieve the first, led DeLee to his dual commitment to aseptic, non-interventionist technique and to aseptic prophylactic interventions. 25
Concentrating on the prevention of morbidity and mortality, DeLee recognized that different groups of birthing women were threatened with dangers from different sources. He also recognized the variety of skill levels evident among birth attendants. When he entered the practice of obstetrics at the turn of the twentieth century, about half of America’s babies were delivered by physicians and the other half came into the world with the help of midwives.The physicians who attended deliveries were for the most part general practitioners, whose training in obstetrics was stil limited in its practical aspects.26 DeLee believed that any plan to improve
maternity practices had to develop tactics suited to all of the various existing situations.He wrote about the necessity for a single standard of good obstetrics for all women, but he acknowledged that, at least in the short run, it could not take identical forms.
DeLee thought that midwives, who attended most immigrant, black, and poor women in Chicago, gave the most inferior care. Like many of his medical colleagues,he decried the lax training, lack of professionalism, and cultural variability among midwives. Moreover, he believed that midwives, because of their community and cultural roots, lowered the “dignity of obstetric art and science.” The first line defense in lowering maternal mortality for DeLee was to raise the status of the medical profession. He knew that some midwives practiced excellent obstetrics and he acknowledged that often times physicians delivered substandard birthing room care. But he thought there was hope to upgrade the practices of physicians whereas he insisted the evidence suggested that midwives were unchangeable. European nations, he noticed, had “ ailed miserably” in their attempts to improve the practices of midwives. 27
His rationalization for putting midwives out of business was his position against what he identified as a “double standard” that gave rich women superior care and poor women an inferior kind of care. DeLee wanted all women to have access to first-class obstetrics, and this he defined as medicall-directed, even at the same time he admitted there would continue to be different standards within medicine itself. The single standard came from making all childbirth medical.
DeLee’s ideas illustrated his bias in favor of elite education and notions of expertise. His position was undoubtedly self-serving. As the son of an impoverished immigrant family who had worked his way up the social ladder, he now defended the climb. Midwives represented what he had left behind; he needed to believe that his efforts had been worthy.
But it would be a mistake to judge DeLee’s choices only in these terms. The excitement of medicine in this period in which the practical application of bacteriology promised new solutions to previously intractable problems was extremely compelling, and DeLee was not alone in falling under its spell. The culture at large was responding to the lure of science’s promises, rejoicing that, as an article in Good–Housekeeping put it, “childbirth is being lifted out of the realm of darkness into the spotlight of new science.”29
DeLee genuinely believed-along with most of his medical and lay contemporaries-that medicine offered the best route to maternal health and safety. To suggest his dedication was genuine is not to deny that it was also self-serving. As a member of a medical specialty striving to prove itself, DeLee saw the obstetricians’ interest and the mothers’ interest served by medicalizing childbirth.
Thus DeLee’s first step in upgrading services available to poor women was to replace their traditional midwife attendants with well-trained general practitioners who worked in women’s homes. DeLee’s free home delivery service at the Maxwell Street Dispensary was to serve the dual purpose of training generation physicians in aseptic procedures and providing quality services to poor families. He hoped that through regimented management techniques, his trained birth attendants — physicians and nurses, not midwives — could reduce to a minimum the dangers associated with many home deliveries. DeLee set out to prove that the dispensary could achieve excellent results with very small needs, and the statistics consistently reported {low} maternal mortality rates that the rest of the city and the nation did not match until the antibiotic era.3″
On a shoestring budget, with general practitioner attendants, and within the tenement homes of the inner city, the maternity center staff offered a high degree of safety to women who previously had been at risk for death and significant debility. The techniques were always non-interventionist, based on watchful waiting, long hours, and skillful aseptic care.
Prophylactic forceps {were not part of} maternity practice at the dispensary.
DeLee’s strategy was in part pragmatic. Realistically, women could not be reached in expensive hospitals. Not only did their cultural values prohibit their entering
institutions,but they could not afford the services, nor could the city afford public hospitals large enough to accommodate this group. The hope for the obstetric safety of the vast numbers of poor urban women rested with improving home-based care.
… of all the options available for upgrading home maternity services, DeLee chose to emphasize medicine over midwifery. He could have advocated improved midwife training pro-grams, fitting his solution to the prevalence of midwives in turn-of-the-century Chicago and to his loyalty to the immigrant community from which he came. This choice would have been consistent with his belief that most labors could safely progress with “watchful expectancy” as long as danger points could be recognized and provided for. But DeLee instead looked to his new identity group, the profession of medicine, for his answer to the problem of high maternal mortality. His faith rested with the “experts”.
This is not to say that DeLee cared more about the profession than he did childbearing women. He cared for both. He saw that the interests of both intertwined: through upgraded medicine women’s lives would be spared. The choices he made underscored his basic confidence in scientific applications and reflected the optimism of an immigrant who had made his own way. With the advantages of hindsight,
historians can see that a choice in favor of strictly trained midwife attendants also could have led to decreased maternal mortality (as it did in Western European countries), but DeLee himself could not believe this. A product of his particular social circumstances, he rejected the authority of tradition and accepted the authority of science; he lived with a faith in progress. DeLee’s blindness to the effects of his policies, to the plight of the midwife or to the possible dangers of increasing the the medicalization of childbirth, is explained by his belief in the potential and promises of the new medicine.
DeLee’s system was two-tiered, just as the culture he
saw around him in urban America. The services of the
Maxwell Street Dispensary, while adequate for those who
could not afford the finest medical services, did not permit the full exposition of what medicine had to ofer. Thus DeLee had other ideas for the women who were not limited by their
finances to minimize on medical interventions. These more
prosperous women, too, faced significant risks to health and
life from their childbearing experiences.They did not suffer, DeLee observed, from faulty midwife attendance, but more
often were victims of faulty medical procedures. Not
knowing when to intervene, not sufficiently familiar with many obstetric techniques, and rushed to get on to the next patient, many physicians put women at great risk by practicing low-quality midwifery {i.e. does not refer to midwife-type care but the notions that poor medical care was essentially the same as care provided by midwives.}
Higher quality obstetrics, DeLee believed, especially in the hands of specialists using the latest techniques, could bring increased safety to this group of women. Instead of needing the regimentation of traditional obstetrics as did poor women, the more affluent could take advantage of the new heights achieved by twentieth century medicine. Carefully monitored interventions, such as prophylactic forceps, or labor induction, which DeLee advocated in 1907, and hospitalization in “exquisitely equipped” maternities — such as DeLee’s Chicago Lying-in Hospital — could enhance the childbirth experiences of many advantaged women who were needlessly endangered during their confinements. 32
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DeLee was among the first to recognize that pregnant women who entered the expanding numbers of hospitals in the early twentieth century did not necessarily fare better than their sisters who remained at home to deliver their babies. Cross infection was rampant in general hospitals, and countless women fell victim to postpartum infections that they might have avoided at home. Maternal death rates remained high for hospital-going women, even when they were attended by specialist-trained obstetricians. DeLee admitted in 1926 that:“the maternity ward in the general hospital of today is a dangerous place for a woman to have a baby.”34 Even so, he continued to believe that the future of obstetrics lay in the hospitals,and he worked hard to convince his profession.
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DeLee’s use of the language of prevention for both
intervention and lack of intervention fit his vision of healthy motherhood to be brought about through the medium of expert medicine. With over 25,000 American women dying from childbirth-related problems each year, the response of the medical and public health professions had to be suited to the particular problems. Not all women had the same experience of childbirth, nor did the dead die from the same problems. Prevention of high infant and maternal mortality, if it was to work, had to be relevant to all the situations in which women gave birth. It was medically logical for DeLee that prevention take many forms.
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He believed that advocacy of his methods would help the cause of the developing obstetric specialist: it would contribute to the scientific and systematic practice of obstetrics by spreading the hospital-based use of specialists’ techniques such as prophylactic forceps and would raise the standards of all obstetric through more general practitioner-oriented aseptic home-based techniques. Thought the multi-dimensional concept of prevention in medical practice, DeLee hoped to give birthing women the safety of the new medicine at the same time as obstetricians were elevated to the status of surgeons.37
To DeLee and his followers, the union of medical practice and public health in the first decades of the twentieth century ideally would have promoted public health interests at the same time as it helped the development of the specialty of obstetrics.
But a causal relationship between the decline in maternal mortality and the rise of the obstetric specialty cannot be demonstrated. Despite DeLee’s local efforts and successes, national maternal mortality rates did not begin to drop at this time. Specialists, working in hospitals with the newest equipment and technology, could not bring down mortality and morbidity rates in the 1920s and early 1930s when increasing numbers of middle-and upper-class women entered the hospital for their confinements.
As a study by the New York Academy of Medicine in 1933 revealed, maternal mortality rates did not respond to the increased hospitalization of birthing women. These physicians showed that the increased use of operative procedures in hospital obstetrics led to maintaining high maternal mortality.38 The lasting effect of the union between the specialty of obstetrics and the rhetoric of prevention, instead, was to upgrade the status of the specialty and to gain it a place in the increasingly competitive world of twentieth century medicine.
Historians have attributed to him a rather single minded devotion to building a medical specialty and in medicalizing a previously unmedicalized event. His 1920 article promoted this image, and the multifaceted nature of his work-and its emphasis on prevention-had not previously been analyzed.
Historical interpretations of DeLee’s championship of interventions such as prophylactic forceps rightly should emphasize the prophylaxis rather than the forceps. The forceps were the means to the end of increasing safety of affluent birthing women by systematizing labor and delivery under the care of obstetric specialists. DeLee’s advocacy of upgrading obstetrics practice by replacing midwives with trained physicians also was part of his effort to prevent the high maternal deaths among the large numbers of poorer women then using the traditional attendants.
Similarly, his campaign to improve the physical structure of hospitals was to prevent the fearsome mortality associated with the move of childbirth into the medical institutions.
That the result of all of these policies was to increase the medicalization of childbirth in the twentieth century was part of their prevention-oriented original intent and meanings; DeLee believed medicine (preventively practiced) would rescue women from the dangers of childbirth. The marriage of public health and medical practice, allowing as it did for pluralistic yet controlled approaches to the problems childbirth then posed, promised to DeLee the best chance to save the lives of the thousands of birthing women who needlessly died each year.
end – Page 1359
