The Gender Gap Writ Large for Childbearing Women & their Midwives ~ draft chapter from (unpublished) “Disturbing Story of Obstetrics in America 1910 to 1980”

Unassigned Chapter from the “Disturbing Story of Obstetrics in America 1910 to 1980

The gender gap writ large in regard to childbearing

When care provided during childbirth was taken out of the hands of women as midwives and taken over by male doctors,  we women as mothers and midwives were the biggest losers — to the tune of more than 10,000 new mothers dying of from fatal infections every year from 1900 to 1937.

But this “changing of the guard” from midwifery to obstetrics was further hobbled by a unique form of gender-discrimination “by association” that tainted the normal respect that  doctors have for other doctors if they were providing women having a baby. In other words, the medical profession as a whole, the vast majority of whom did not attend births, verbally demeaned and belittled doctors that provided care to childbearing women.

Another aspect of gender-specific prejudice can be seen in the historical title that doctors used to describe themselves and one another. For reasons that are unclear, doctors of the era insisted on being referred to as “medical men” instead of using the academic title of ‘doctor’; this gender-specific title obviously emphasized the practice of medicine as male-centric discipline. As such it’s not surprising that “medical men” were prejudiced against other “medical men” who referred to themselves as a “man-midwives” and professionally attended women in childbirth.

The most extraordinary and belittling and demeaning comments that “medical men” made about “men-midwives” in early 20th century was to say that attending a birth was no more of medical activity than:

” … a terrier dog sitting in front of a rat hole waiting for the rat to escape”.

I found the intensity of this prejudice to be shocking. While the remark was certainly clever, it also was inexcusably crude, describing the skills required for attending a birth to be nothing more than a dog sitting around and waiting for a rodent to come out.

That not only communicates disrespect for women and female biology, but also  “quilt by association” — simply by being in the company of women or providing to care to them was debased to a “medical man”. yourself.

Unfortunately, a big and very central part of the story of obstetrics revolves around the male of the species and their assumption that men quite naturally do everything better than the female gender.

For obstetricians in leadership roles in the early 20^th century, the very specific gender-related target was midwives. The issue was how to totally eliminate the practice of midwives and erase every trace of the ‘silly’ idea that childbirth was a normal aspect of an adult woman’s biology and not a medical procedure. Were this the actually case (and it was) it would be reasonable and rational for midwives to function as primary birth attendants for a healthy pregnant woman. That certainly was not what American obstetricians had in mind!

Nonetheless, the history of midwifery is an honorable one that goes back more than 5,000 years to ancient Egypt, where it was an organized discipline with trained practitioners. As recorded in Egyptian hieroglyphics, midwives were the very first to provide a ‘preventive’ healthcare service, which predated the practice of allopathic medicine by several thousands of years.

Unfortunately the obstetrical profession saw the long and honorable history of midwifery as irrelevant, since their only goal was to make midwives disappear, never to be seen again! The rational explaining why obstetricians were right, and midwives were all wrong, started with the dubious claim that childbirth was actually a very dangerous and quasi-pathological form of biology.

Doctors described the undependable nature of female reproduction as a mistake (or bad joke) by Mother Nature that destined women to die after giving birth the way salmon die after spawning. Early twentieth century publications by influential obstetricians officially defined childbearing as a “nine-month disease” that required a “surgical cure“. From this perspective, childbirth were obviously the profession ‘property’ of medical doctors, just as much as a patient having a  gallbladder attack.

The Midwife Problem Writ Large

Politically, the midwife problem in the United States was eerily similar to the “immigrant” problem, the “colored” problem, the “Jewish” problem, and the “women’s suffrage” problem“, as it gave rise to formally organized and well-funded attempts by the upper echelons of society to get rid of a demographic of which they didn’t approve. In this case, it was obstetricians that decided to turn thus burning urge for purging society of nare-do wells, misfits on other “undesirables” on midwives as a class.

If you count colorful language, searing invectives, I have to say they did a damn fine job!

In 1906, Dr. Gerwin described midwives as:

“ the typical … midwife, her mouth full of snuff, her fingers full of dirt and her brain full of arrogance and superstition”

A paper by Drs. Emmons and Huntington in 1907 criticized midwives for:

“the overconfidence of half-knowledge, …unprincipled and callous for the welfare of her patients”

But one of my favorites is from “Remarks on the Employment of Females as Practitioners in Midwifery; Published Cummings & Hilliard – Boston, 1820

“It is one of the first and happiest fruits of improved medical education in America, that [midwives] were excluded from the practice; and it was only by the united and persevering exertions of some of the most distinguished individuals that our profession has been able to boast {that} this was effected.”

The opinions typically voiced by obstetrician during most of the 20th century were extremely prejudiced about the practice and fundamental humanity (i.e. one’s right to exist) of midwives. This really is a built in bias that say I and my “kind” are 100% ‘right’, while all those “others” are all wrong. This is the very same kind of thinking and disparaging comments that many white southerners regularly made about people of color during the years I was an L&D nurse in a segregated hospital southern. Sadly, the pervasive prejudice against midwives by the medical profession — particularly  obstetricians — is still alive and going strong in 2023.

Link to video reporting non-consensual practices used by contemporary obstetricians 

One contemporary example are remarks made by MDs appointed to our state medical board. More than a quarter century after passage of the “Licensed Midwifery Practice Act of 1993“, which provides for the state-wide licensing of professionally trained midwives, physicians are still referring to us as “lay midwives”. This is a passive-aggressive way to dismiss and disparage traditional midwifery as an inferior form of maternity care.

But in the early 20th century, the “midwife problem” described the problem obstetricians had in getting rid of midwives and erasing any fond memories of them. As described by obstetricians, midwives as a class were untrained, unclean, uncouth, uneducated, and their practice unconscionable. Actually, 40% of practicing midwives graduated from a professional midwifery training program before immigrating to America and they helped to improve the practice of lay midwives.

However, these facts didn’t matter to the obstetrician-architects of an anti-midwife PR campaign waged over several decades in newspapers, women’s magazines and radio programs that promoted obstetrical care while disparaging midwives. While there are many examples of these invectives, these two are particularly demonstrative of the Hundreds Years War that the American obstetrical profession has been and continues to wage against midwives.

But of all the big and little sins obstetricians ascribed to “the midwife”, the biggest and most unforgivable was what obstetricians deemed to be an illegitimate form of economic competition. They believed that only practitioners who graduated from medical school were qualified to attend “cases of childbirth”. Since midwives hadn’t graduated from medical school, all the fees they received had, in effect, been stolen from doctors.

Doctors also claimed the practice of midwives was indirectly responsible for the poor medical school training students received in obstetrics. Doctors and health officially both agreed the the quality of American medical schools was embarrassingly poor.  This generally dismal state of affairs was a constant topic of conversation and stinging criticism by politically-active obstetricians. The biggest issue for them was the sky-high maternal mortality rate in the US compared to other industrialized countries, and sad fact that so many of these deaths were preventable. Galling as it was to admit it, the medical profession was acutely aware that these maternal deaths were ultimately a result of medical schools failing to properly train its students in obstetrics.

While its professors demonstrated techniques for cutting episiotomies, extracting breech babies, using forceps and manually removing placentas, the vast majority of medical students did not have any actual clinical training in obstetrics. This meant no real-time experience in the decision-making process — whether or when to use such invasive procedures, and no hands-on practice to learn how to use them safely.

After graduation, newly minted doctors eagerly into went into private practice as GPs, having been told by other doctors that

“…. obstetrics opens the way to family practice which, after all, is what he wants” {Dr. Ziegler: “How Can we Best Solve the Midwifery Problem” 1921, page 409}.

This was not a new idea, because it was first published  in a 19th century (1820) publication and makes its economic goal crystal clear:

”Women seldom forget a practitioner who has conducted them tenderly and safely through parturition (childbirth)…”

It is principally on this account that the practice of midwifery becomes desirable to physicians.  It is this which ensures to them the permanency and security of all their other business.

“Remarks on the Employment of Females as Practitioners in Midwifery; Published Cummings & Hilliard – Boston, 1820

Following this sage advice, new MDs offered their services to several rapidly growing families and quickly found themselves very busy delivering babies. Since this can be time-consuming, inexperienced doctors frequently used forceps and manually removed placenta to hurry things along. As already noted, the US had a disproportionately high MMR compared to other developed countries, but what was particularly disheartening to those “in the know” was that the maternal mortality rate for doctor-attended births was several times higher than those attended by midwives.

In spite of the verbal temper tantrum many obstetricians had every time they heart the word
“midwife”, it turned out that the practice of midwives had little or nothing to do with the high and continually climbing MMR in the US. Instead it the poor-quality care provided by poorly trained doctors using forceps and pulling placentas out in their hand that had so increased rate of maternal deaths.

In the days before antibiotics became available, midwives wisely didn’t cut episiotomies, didn’t use forceps and didn’t reach up into the mother’s uterus and pull the placenta out. As a result, the likelihood of triggering a fatal hemorrhage or the new mother dying from a raging infection was orders-of-magnitude lower, which is to say, very much safer.

While the explanation was both straightforward and simple enough, doctors didn’t want to hear it and they certain didn’t intend implement it themselves. By turning their backs on the what was stastically proven to be  actauly was a very easy solution — just don’t intervene in normal labors as a stradgy for  Between 1900 and 1937, fatal infections were directly responsible for 10,000 deaths annually.Instead, they

Dr J. Whitridge Williams, 1912:

“The question in my mind is not “what shall we do with the midwife?” We are totally indifferent as to what will becomes of her…[1912-B, p.225]. No attempt should be made to establish school for midwives, since, in my opinion, they are to be endured in ever-decreasing numbers while substitutes are being created to displace them.” [1912-B; p.227]

Dr. Joseph DeLee’s 1915 publication “The Teaching of Obstetrics“; American Association of Obstetrics and Gynecologists

“The midwife has long been a drag on the progress of the science and art of obstetrics. Her existence stunts the one and degrades the other. For many centuries she perverted obstetrics from obtaining any standing at all among the science of medicine.

The midwife is a relic of barbarism. In civilized countries the midwife is wrong, has always been wrong. The greatest bar to human progress has been compromise, and the midwife demands a compromise between right and wrong. All admit that the midwife is wrong.

If the profession would realize that parturition [childbirth], viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention.” [TASPIM, 1915 p.117]

[Transaction of the American Society for the Prevention of Infant mortality (TASPIM) 1915, p. 114]

The gender-loaded title of “Medical Men”

Most people don’t know that in the early 1900s, medical doctors in the US didn’t like being called “doctors”, which was more strongly associated with college professors and the ministerial title “Doctor of Divinity”, and they hated being referred to as a “man-midwife”. Instead they preferred being the descriptive title of “medical men”. A comment by no less an icon of obstetrical wisdom than Dr. J. Whitridge Williams demonstrates the nature of this gender issue:

“Have you ever considered,” he said, “the economical significance of the fact that three out of every five women are more or less incapacitated for several days each month, and that one of them is quite unable to attend to her duties?

Granting that the two sexes are possessed of equal intelligence, it means that women cannot expect to compete successfully with men. For until they are able to work under pressure for 30 days each month, they cannot expect the same compensation as the men who do so.”  {Twilight Sleep: Simple Discoveries in Painless Childbirth; 1914}

During this formative period of American obstetric as distinct from its practice in other developed countries, the profession never doubted that Mother Nature, having blessed male MDs with the superior intellectual powers conferred by their “y” genes, meant it was their divine destiny to rescue the millions of white middle- and upper-class women who gave birth each year from a malicious Mother Nature.

American obstetricians believed it was both their right and their duty to be in charge of female reproduction, which meant that they controlled all aspects of pregnancy and childbirth in the United States.

“A Review of the Midwife Situation” ~ Boston Medical and Surgical Journal, 02-23-1911, page 261 {*} Arthur Brewster Emmons, 2d, M.D., Boston and James Lincoln Huntington, M.D., Boston.

“… 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.”

These outspoken and politically-active obstetricians concluded that childbirth could safely be described as a relatively normal aspect of reproductive biology in women of color, immigrants and the working poor. The sheer size of the average poor or immigrant families – as 15 or even 20 children – attested to that. However, these same influential obstetricians insisted that normal labor and spontaneous childbirth in the upper classes of (white) women had somehow become a “pathophysiology”, that is, a dangerously dysfunctional aspect of female biology.

Having concluded that the lower classes of working poor did not particularly need, nor were able to pay for obstetrical services, the profession turned its attention to middle- and upper-class white women, whose families could easily afford an obstetrically-managed hospital birth. This serendipitously coincided with the more advent-guard ideas about making childbirth more “modern” by identifying obstetricians (i.e. not midwives) as the preferred birth attendant for the wealthier and whiter classes of women.

Articles by obstetricians published in newspapers and women’s magazines and broadcast on the radio, all described pregnancy and childbirth in the “modern” American (i.e. white) woman to as a “nine-month disease that required a surgical cure”. As spokesmen for the obstetrical profession, they were outspoken and relentless in promoting the idea of “always a doctor, never a midwife”.

Having defined normal childbirth to be pathology, professional services associated with the ‘disease’ of childbirth was, without question, to legally become the sole “property” of the obstetrical profession. Since ‘new’ obstetrics was defined as a surgical specialty, the proper way to refer to childbirth as attended by “medical men” was now referred to as “the delivery”, a term that defined childbirth to be a sterile surgical procedure conducted by an MD trained in obstetrical surgery.

This process began by putting labor patients to sleep with chloroform or ether and having the nurses cover the laboring woman with sterile drapes. Then the doctor stepped in to cut an episiotomy and extract the baby with the use of obstetrical forceps.

By defining childbirth as a pathology, the doctor was required to remove the placenta manually (i.e. to use his hand) instead of waiting for it to be spontaneously expelled. In order to detach the placenta from the uterine wall and bring it out in his hand, the doctor he had to put on a special sterile glove with a long cuff that went up to his elbow. Then he inserted his hand and forearm into the mother’s vagina in order to reach inside her uterus and peel the placenta off the inner surface of the uterine wall, grab the separated placenta with his fingers, and draw it out of the uterus and the mother’s vagina.

Last but not least, the surgical process of childbirth end when the doctor finished suturing of the episiotomy incision.

Note that childbearing woman were no longer described as “giving birth”, but seen as passive entitled whose baby was extracted from her unconscious body by forceps, and thus establishing that it was the doctor, and not the mother, who “delivered” the baby.

For healthy childbearing women, this was the most profound change in childbirth practices in the history of the human species.

Continued Ch ??