A Review of the Midwife Situation ~ Boston Medical & Surgical Journal ~ 1911
The Boston Medical and Surgical Journal
Volume CLXIV January-June 1911
A Review of the Midwife Situation
by Arthur Brewster Emmons, 2d, M.D., Boston
and James Lincoln Huntington, M.D., Boston.
pages 251-261
LEGAL SITUATION
Before taking up possible means of improving the situation in Massachusetts in solving our present difficulty, let us take a look at the more strictly legal aspect of the situation. Of the other states in the Union, fourteen recognize the midwife by expressly exempting her from the provision of the medical act. Most of the states ignore the situation entirely; probably in many of these the midwife plays a very unimportant role, if any at all.
In the few states that have attempted to license and regulate this class of practitioners, their attempts in the light of what we have seen in other parts of the world are pitifully futile. No state has successfully solved the problem. Those that have passed laws for their regulation throughout the state have, in our opinion, made the solution of the problem more difficult.
We in Massachusetts are in a most fortunate and enviable position. In the first place, the number of midwives existing is small and without influence. They are practicing in open defiance of the law. In excluding these women from practice by enforcing the law, we would not be depriving a large class from earning their livelihood.
Neither would we be depriving any considerable portion of society of proper care. We are particularly fortunate in having a definition of the practice of medicine handed down by the Supreme Court of our Commonwealth, directly applying to the practice of the midwife. The following is a quotation from the opinion handed down by Mr. Justice Rugg.
He writes:27
“Revised Laws, Chapter 76, Section 7, mentions obstetrics as one of the subjects of examination for the purpose of testing an applicant’s fitness to practice medicine. This goes far towards showing that obstetrics is a branch of the practice of medicine.
It requires no discussion to demonstrate that when, in addition to ordinary assistance in the normal cases of childbirth, there is the occasional use of obstetrical instruments, and a habit of prescribing for the conditions described in the printed formulas which the defendant carried, such a course of conduct constitutes the practice of medicine in one of its branches.
“Although childbirth is not a disease, but a normal function of women, yet the practice of medicine does not appertain exclusively to disease, and obstetrics, as a matter of common knowledge, has long been treated as a highly important branch of the science of medicine.“
There have been at least two convictions in the state under the present law.28 But while this shows that prosecutions are possible, it is admittedly a fact that such a process is by no means easy.
Complications in the legal machinery, not to say defects, make it difficult to bring the midwife before the bar of justice. In the first place, there is no easy method of lodging a complaint. The Board of Registration of Physicians is not empowered to discover violations of the law relating to the registration of physicians.
That law distinctly states29 that the board shall investigate all complaints of the violation of the law and report the same to the proper prosecuting officers. Thus the board does not act until a complaint is brought to them that an individual is practicing medicine without being properly licensed. Then, and not till then, it has the power to act, but persons are not anxious to go out of their way to stir up trouble unless some flagrant case arises. Should the physicians at large know that they can bring in a complaint to the Board of Registration, and yet conceal their identity, possibly more complaints would be made and more cases prosecuted.
But it is also difficult to secure sufficient data to bring about a successful prosecution. The present law for the registration of births allows so much time to elapse before the certificate must be handed in that it is often difficult to trace the case.
But more important than all is the fact that public sentiment is not sufficiently aroused to make convictions popular. In many localities officers of the law are unwilling to prosecute cases even when the law and its violations are directly brought to their attention.
In one city in Massachusetts when the city marshal was informed of the law and the fact that a midwife was openly violating it, and that by a decision of the Supreme Court the midwife was liable, he replied that in his opinion the judge who would make such a decision merely gave evidence of intoxication.
When such is the popular feeling, we cannot expect much result from the laws as they now exist, or in mere modification of the law. What we must first do is to arouse public sentiment, and first of all we must have the enthusiastic support and united action of the medical fraternity.
That the situation in Massachusetts is in need of improvement, we admit most frankly. We also feel that minor changes in the present laws cannot be made too quickly, and we urge strongly that side by side with the education of the community to combat this evil should go changes in legislation which will make the laws consistent and easier of enforcement.
We feel that the most important change should be in the laws governing the registration of births. The word “midwife” as it occurs, should be at once erased from the statute books.
The certificates of birth should be returned by the physician promptly; the form of the certificate could also be improved by providing a means of identification of the person actually responsible for the delivery of the patient. We also feel that theoretically better results would be obtained should the birth certificate be inspected by the board of health within three days of the birth of the child. Under the present law death certificates have to pass through this channel, and suspicious cases are referred by this board to the medical examiner. Would not inspection of birth returns by the board of health assist in furnishing evidence useful in the prosecution of questionable practitioners?
Another law which we feel could easily be amended and which would give better results is one to strengthen the Board of Registration in Medicine. This might read something as follows: “An Amendment to the Revised Laws, Chapter 76, Section 6:
“It shall be the duty of the board furthermore to keep itself informed of the condition of the practice of medicine throughout the Commonwealth, to the end that illegal practice of medicine, as defined in this law, may be prevented. In order to secure the information required by this act there may be expended a sum not exceeding $2,000 annually.”
Above all, we must make the physicians of Massachusetts thoroughly aware not only of the existing conditions of midwifery in Massachusetts, but of how they can aid by doing their duty in the enforcement of the law to the benefit of the community. In those cities and towns where the problem is greatest, the physicians should see to it that provisions are made for an out-patient, lying-in department as an accessory to the local hospital.
A brief study of such institutions in Boston would show how easily such a department can be carried out, and how easy it would be to make it practically self-supporting, and what a benefit such an institution would be to their community. The professors of obstetrics in the medical schools of Massachusetts should impress upon their students not only the importance of post-graduate work in a lying-in hospital, but also where in the state such appointments can be had.
Thus by co-operation between the local practitioners in the communities where the midwife now flourishes, and the professors and students of our medical schools, not only could the present midwife situation be greatly improved, but also the medical student would have a better opportunity to obtain training in this important branch of medicine.
CONCLUSION
In reviewing the midwife situation abroad and in our own country, much has been said, but far more might be said of the unsatisfactory condition of obstetric practice wherever the midwife exists. Two standards of skill and a divided responsibility inevitably are found. The midwife must either be a competent, trained obstetrician, or she must become a subordinate, co-operating with the obstetrician, as does our excellent trained obstetrical nurse, relying on his judgment and resting with him the responsibility of the two lives, before a system harmonious and satisfactory can result.
The history of temporizing with the ignorant, half-trained, often malicious midwife in our sister states to-day reads like many another misguided “freedom ” which is virtually a license by the state to practice quackery on an ignorant, unsuspecting public. The women and infants pay for this “freedom” in deaths, unnecessary invalidism and blindness.
Who are to blame? Is it the ignorant public? Shall we blame the legislators? We believe it to be the duty and privilege of the medical profession of America to safeguard the health of the people; we believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth. The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public.
A resolution of the Women’s Municipal League awaits only a formal endorsement to urge the importance of legislation, not for the licensing and regulating of the midwife, but for such minor changes in the laws as will make the present statutes effective in dealing with the midwife in Massachusetts.
It has remained for this and other active charitable organizations to point out the necessity for bettering obstetric conditions in the state. Let the medical profession, we urge, not only cooperate with these forces for good, but let us obstetricians consider well the situation in obstetrics throughout the state to-day; let us look into the future and consider means for furnishing efficient trained service to rich and poor alike.
Our worthy predecessors of this town,30 a century and a half ago, retired the midwife to oblivion as having passed her age of usefulness. Oliver Wendell Holmes 30 over seventy years ago, by his monograph on the “Contagiousness of Puerperal Fever,” led the world to the safeguarding of the mother during childbirth.
Two recent papers, “When to Interfere in Pregnancy and Labor,”31 and “The Fundamental Conceptions which should Govern Modern Obstetric Practice,”32 read by two members of this society, are convincing proof that the best knowledge of practical obstetrics to-day is here available, and, moreover, the lines for advance are being laid out for the future.
A golden opportunity awaits the obstetricians of Massachusetts to-day to carry on this high standard. Our already fairly satisfactory system should be maintained and advanced along the lines of the most progressive sociologic, economic and obstetric knowledge of the day.
Thus Massachusetts may be kept in her position of leader, guide and example of the best, safest and most efficient system of obstetric practice in this country and throughout the world.
BIBLIOGRAPHY:
27 (Legal) Mass. Board of Registration in Medicine, Sixteenth Annual Report, p. 23. Public Documents No. 56, Dec. 31, 1909.
28(Legal) Ibid., pp. 18 and 23.
29(Legal1) Ibid., p. 14.
30Holmes, Oliver Wendell: Medical Essays, 1843.
31Newell, F. S.: Boston Med. And Surg. Jour., vol, clx, p. 805, June 29, 1909.
32Reynolds, Edward: Ibid., p. 799.
