The Wrong Use of Obstetrics
An Expensive and Deadly
American Tragedy
~ June 2024 ~
Background: This is the true story of Dr J.W. William’s dream of a nationwide system of general hospitals using fund generated by the elective hospitalization of healthy wealthy maternity patients as told in the 1914 book “Twilight Sleep: Simple Discoveries in Painless Childbirth”.
His efforts directly laid the groundwork for the 20th century practice of obstetrics in the United States as a new surgical specialty. Childbirth in 1910 was seen as potentially dangerous “pathophysiology” that the heartland of America (often described today as “fly-over country”) was dotted with 8,000 or so two-to-ten bed (best historical estimate) private, for-profit hospitals owned and run by one or two of the town’s doctors. However, most of the smaller facilities were more like a “nursing home” than a modern hospital, with “medical technologies” that mainly consisted of electricity, a telephone, a microscope, and maybe an older x-ray machine.
Overview: After graduating from medical school in 1888, Dr. JWW went to Europe for advanced clinical education. He enrolled in two different clinical training programs which provided four years of clinical training (hands-on learning) in the best hospitals in Western Europe. He was particularly struck by the European system of large, well-equipped, well-staffed general hospitals able to provide comprehensive medical and surgical services in every geographical region of the European Continent.
This was particularly striking as the United States only had a handful of “general” hospitals. After an exhaustive attempt to find a published statistic for this, my best estimate was less than a hundred or so in the whole country. The vast majority of these general hospitals were in the heavily populated northeast corridor, Chicago, Atlanta, New Orleans, Denver, and the largest coastal cities such as LA, San Franciso and Seattle.
The rest of our big country, pejoratively described today as “fly-over country”, was dotted with 8,000 (best historical estimate) or so two-to-ten bed private, for-profit hospitals owned and run by one or two of the town’s doctors. However, most of these smaller facilities were more like a “nursing” or “convalescent” home” than a modern hospital, as their “technologies” mainly consisted of running water, electricity, a telephone, a microscope, and maybe an older x-ray machine.
However, if your family lived on a farm in rural Kansas, Oklahoma, or Arkansas, or another “fly-over state”, and had the misfortune of a loved one with a really serious illness, or your farmer-husband got his arm caught in the teeth of a tractor and was bleeding profusely, and assuming you had a gassed up-car, you’d be lucky if you only had to drive him 50 to 100 miles to a well-equipped general hospital.
Unfortunately, many families living in rural areas and farms more than an eight hours driving distance from comprehensive hospital care. Sick babies, women in an obstructed labor or hemorrhaging due to a retained placenta, desperately injured children and adults all died tragically before finally arriving at a hospital large enough to have provided the desperately-needed medical care.
Dr. JWW was acutely aware of just how ‘backward’ the US was compared to Europe, and how badly we needed a similar system of general hospitals in the US like those in other wealthy industrialized countries.
A big dream matched by a big “plan”
However, Dr. JWW not only had a dream but also had a “plan”, one that would replicate the effective system use in Europe here in the US. The only functional difference would be the source of funding: a tax-based system like the one used in Europe (nationally-funded hospital system) or a free-enterprise system such as the one used by privately-owned, for-profit hospitals in the US.
Europe’s nationalized hospital system was paid for by taxpaying citizens, while American hospitals were an “entrepreneurial” undertaking — privately-owned ‘for-profit’ businesses. Their MD owners did not need nor want any kind “government money”, as they were sure it would come with dozens of “strings attached” that would tie the doctor up in knots! Government funding would pave the way for government bureaucrats to tell doctors how to practice medicine, thus usurping the sacrosanct “doctor-patient relationship”, something to be avoided at all cost!
But not to worry because Dr. J. Whitridge Williams’ had a “Plan” that completely eliminated “government interference”. Granted, it was going to be a slow, multi-step process that required the doctor-owners of hospitals to (as the Irish say) “take the long way ‘round by Canarsie”. However, Dr. JWW’s plan for self-funding was the quintessential gift that keeps on giving in perpetuity!
His Plan had two interconnecting parts. The first part was a very clever economic plan that would self-fund the upgrading and modernization of small hospitals, and the second part was a nearly fool-proof the plan that would result in the reliable “patronage” of middle and upper-class white maternity patients as paying customers and endless source of “repeat business” for hospital labor and maternity wards.
How many of us realized that every pregnant woman who has a baby in the hospital not only utilizes its labor and delivery services and tradition 14-day “lying-in” stay in its maternity wards, but she is also directly responsible the admission of a second hospital patient – a newborn baby — to the hospital’s nursery! Also few of us realize that the vast majority of hospitalized maternity patients are relatively young and generally healthy. They take very little of the nurse’s time, as these new moms are mostly able to care of themselves and their new babies.
Maternity wards are happy places mostly populated by healthy “patients”. who are also happy new mothers. According to a newspaper report published in the 1990s, the maternity department of typical general hospital generates a profit margin of 38 cents for every dollar received by the hospital. This was in sharp contrast to cardiac and other specialty med-surg units, which only generated 5 cents of profit per dollar received by the hospital.
However, the economic impact of this new and steady stream of “paying customers” (i.e. middle and upper-class white maternity patients) over the course of several decades far outstripped its numbers. The constant stream of white upper-class maternity patients dependably generated a revenue stream for each small hospital that allowed them to use this new income to upgrade and modernized their facilities.
However, it’s safe to assume that a significant number of these smaller hospitals, would be able to turn this income — the “gift that keeps on giving” from maternity patients — as the economic springboard for slowly transforming small hospitals into upgraded and better equipped medium-sized hospitals.
With a little foresight and a couple of decades of time, the income generated by the “baby business” could finance well-equipped and fully-staffed general hospitals that were able to provide comprehensive medical, surgical and emergency services to a large geographical region. That was Dr. JWW’s dream come true!
Dr JWW’s fool-proof plan for self-funding
Dr. JWW’s bold and brilliant self-funding plan was to encourage every small and medium-sized hospital to put in a “lying-in ward”. As soon as that was up and running, these small hospital were encouraged to put notices in all the local newspapers actively soliciting the “patronage” of middle and upper-class white maternity patients by promising that every woman who labored and gave birth in the hospital would have a totally “painless childbirth”.
This would be accomplished by giving Twilight Sleep drugs to every laboring woman as soon as she was admitted to the hospital. Twilight Sleep is a combination of two drugs given by injection every 2 to 3 hours during labor. The first drug was morphine, which is a strong narcotic that causes some level of respiratory depression in newborns at birth. The amnesic-hallucinogenic drug scopolamine is associated with hallucinations and total amnesia during the labor and birth.
When it was time for the baby to be born, the normal spontaneous process of vaginal birth, in which a fully conscious mother pushes her baby out under her own steam, was replaced by the obstetrical term “delivery”.
So-called normal “childbirth” for middle and upper-class white women was referred to as “the delivery”. This was a sterile surgical procedure conducted under general anesthesia in a formal operating room. After being moved by stretcher to the delivery room the laboring woman was rendered unconscious using chloroform or ether. Then her arms were put into leather wrist restraints attached to the side of the delivery table and her legs were strapped into obstetrical stirrups.
Because anesthetized women are unconscious, they are typically unable to push effectively. As a result, their doctors routinely cut an episiotomy and extract the baby with forceps. To avoid wasting time by waiting the 6-to-20 minutes it typically takes for the placenta to be naturally expelled by the mother’s uterus, obstetricians routinely removed it while the mother was still unconscious.
Manual removal of the placenta required the doctor to put on a special sterile glove with a long cuff that almost went up to his elbow. Then he inserted his gloved hand into the mother’s vaginia and up into her uterus and then use his fingertips to separate the placenta from the uterine wall and then pull out in his hand.
Manual removal of the placenta always risks a potentially-fatal hemorrhage. Before antibiotic drugs became available in the 1940s, routinely removing a placenta by reaching up into the new mother’s uterus also put her at risk of dying from an untreatable infection.
Demand for Twilight Sleep drugs quickly turned lying-in wards into the hospital’s very own “cash cow”
This steady supply of “paying customers” (middle and upper class white maternity patients) would dependably generate a revenue stream for each small hospital that they would in turn use to upgrade and modernized their facilities.
It was reasonable to assume that with a little foresight and a couple of decades of time, a significant number of these smaller hospitals would be able to “grow” into a well-equipped and staffed general hospitals that was able to provide comprehensive medical, surgical and emergency services to a large geographical region.
