Wrong Use of Obstetrics ~ earliest versions of all chapters (not part of “Disturbing story of OBs in American)

~~ All Chapters but may not include stand-along chapters on EFM, Pit-2- Distress, epidural, ?? etc ~~

@@@ 23, 134 words @@@

1. Viewing American Obstetrics through the Lens of History

It’s impossible to understand the true nature of our uniquely “American” system of maternity care without first knowing that early in the 1900s, the obstetrical profession embarked on a campaign to transform millions of healthy childbearing women in the US into the patients of the hospital-based surgical specialty of obstetrics and gynecology. The events of this era provided the foundation for the modern practice of obstetrics in American, determined its nature as a surgical specialty and defined the goal of the profession as the universal and sole provider of all childbirth-related services in the United States.

The 5,000-year-old tradition of working with the human biology of childbirth as described in the biblical book of Exodus and many other historical sources, was replaced in the United States early in the 20^th century with a pathology-centric system that defined normal childbirth as a “nine-month disease” that required a “surgical cure”. One prominent obstetrician of the day declared that:

“For the sake of the lay members who may not be familiar with modern obstetric procedures, … care furnished during childbirth is now considered … a surgical procedure.” [1911-D, p. 214]

That the obstetrical profession saw its role as all-encompassing is clear in this boldly declarative excerpt published in Boston Medical and Surgical Journal (02-23-1911, p. 261).

 

“… 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 conclusions and their political pronouncements were not predicated on scientific investigations conducted in the US or public health records from other wealthy countries claiming that the routine use of obstetrical interventions and invasive surgical procedures in a cohort of healthy women with normal term pregnancies had been scientifically established as significantly safer than the non-interventive support traditionally provided by GPs and experienced midwives.

No Scientific Studies to determine if the routine use of obstetrics interventions were safe

Prior to implementing these policy decisions, no scientific studies were every conducted in the US that compared childbirth-related outcomes by determining respective rate of complications, infections, permanent disabilities and deaths in these two very different systems – physiological management by general practice physicians and midwives compared to obstetrical care as a hospital-based surgical specialty.

However, ample public health records did exist from developed countries such as England, Netherlands, and Scandinavia that clearly identified non-interventive midwifery support for the normal biology of labor and birth as substantially safer than the highly-medicalized and interventive approach of American obstetrics. A contemporary study of the historical record for childbirth-related maternal deaths in wealthy countries from 1870 to 1940 entitled “Maternal mortality in the past and its relevance to developing countries today” reported that:

 

“ … maternal mortality rates were very high … where most deliveries were performed by physicians, especially in the hospital. Maternal mortality rates were also high when maximum surgical interference in … normal labors was encouraged or advocated.

 

A leading American obstetrician in the 1920s, Dr. Joseph DeLee (13, 14), wrote a paper entitled “The prophylactic forceps operation” in which he advocated that procedures for ordinary deliveries be changed to include anesthetizing every patient in the second stage of labor, delivering the baby with forceps, and manually removing the placenta …. His advice was heeded by many obstetricians and horrendous examples of iatrogenic mortality resulted.

 

Another unexpected finding related to maternal mortality … was the inverse relation between maternal mortality rates and social class. … the risk of dying in childbirth was higher in the upper and professional classes … than in the skilled and unskilled laborers …

 

The only plausible explanation for this social class difference is that the upper classes were more often delivered by physicians and, therefore, more likely to suffer unnecessary interference, whereas the lower classes were delivered by midwives, almost all of whom were trained by 1930 –1932.

 

As distilled in the abstract, the journal paper concluded that:

 

“…the main determinant of maternal mortality was the overall standard of maternal care provided by birth attendants.

 

Poverty and associated malnutrition played little part in determining the rate of maternal mortality. This view is supported by much evidence … maternal mortality rates tended to be higher in the upper than in the lower social classes.”

Ref: Maternal mortality in the past and its relevance to developing countries today; Irvine Loudon Am Jour Clinical Nutrition, Volume 72, Issue 1, July 2000, Pages 241S–24246S, https://doi.org/10.1093/ajcn/72.1.241S

Normal Childbirth in America Declared to be a Pathology, circa 1910

Ample statistical information on maternal-infant outcomes was available during this historic period (see excerpt of Dr. Ziegler’s 1922 speech on next page ) that linked the high rates of maternal mortality with poor medical training and poor obstetrical practices and made it obvious that “encouraging or advocating maximum surgical interference in … normal labors” was a dangerous policy.

 

However, all this information was simply ignored by the vast majority of obstetricians, while the American obstetrical profession clung steadfastly to its decision to treat normal childbirth as a pathology, a policy both quickly implemented and widely advocated. The problem was that obstetricians took over the practice of midwifery without any idea of the philosophy, principles or techniques of physiological management. They had no appreciation of the safety and other benefits afforded by physiological methods and no respect for the dangers introduced by medical interference and surgical interventions.

The normal biological process, in which a fully conscious and mentally-competent adult woman “gives birth” under her own power, was officially reconfigured by the surgical specialty of obstetric in 1910, when the mother’s active role in her own baby’s birth was also reduced to that of a spectator and the process of childbirth renamed.

Childbearing women were henceforth to be thought of as “surgical patients”, and the birth was now referred to as “the delivery”, a term that described a surgical procedure “performed” by a physician-surgeon on an anesthetized surgical patient. The American obstetrical standard of care called for the “pre-emptive” use of the obstetrical interventions and invasive procedures during normal childbirth as described by Dr. De Lee (see quote above).

During the first 80 years of the  20^th century, the proper role of a surgical/obstetrical patient was to lie unconscious and unmoving on the operating room-delivery table under general anesthesia, legs in obstetrical stirrups, hands by your side in leather wrist restraints, while the doctor performed the surgical procedure of “vaginal delivery”, using whatever manipulations or surgical instruments he required or preferred to extract the baby from the mother’s inert body.

On admission to the hospital, laboring women were isolated from all the normal sources of social support including husbands and other family members, and immediately injected with the combination of narcotics and the amnesia-hallucinogenic drug scopolamine known as Twilight sleep. This was repeated every 2-3 hours until it was time for the baby to be born, which could be as long as 72 hours in some cases.

 

I was an L&D nurse working in hospitals in the south during the 1970s, and obstetrical department policies all called for the mandatory administration of Twilight Sleep drugs to all its obstetrical patients. I still refer to this era as “the Dark Ages of the Deep South”. The pharmaceutical effect of scopolamine is equivalent to a chemical lobotomy, as it eliminates all executive function and memory over the hours of labor and actual birth of the baby. Women under the influence of these drugs are considered incompetent from a legal standpoint and not allowed to make any decisions about their own care or that of their newborn baby. As would be true for any surgical patient under anesthesia, it is up to the doctor to make all the decisions about the patient’s course of care.

 

However, scopolamine does not in any way reduce the pain of labor, it merely obliterates the mother’s short-term memory of it. Drugged labor patients frequently become agitated with each and every contraction, crying out, moaning, trying to climb out of bed and asking with big frightened eyes and a trembling voice: “what’s wrong, what wrong with me?”.

 

During the years I working in hospital L&D wards, I tried to provide an assuring “Nothing’s wrong with you, you’re just having a baby”, but when the next contraction came a few minutes later, the mother became agitated again, and with that same petrified look, ask: “What’s wrong with me?”

During the final phase of the pushing, the narcotized labor patient was moved by stretcher to a special operating room used for conducting the surgical procedure of delivery. Usually the nurse-anesthetist already there, waiting to administer general anesthesia. This was another aspect of what it meant for a childbearing woman to be classified as a surgical patient since being anesthetized automatically goes with surgery.

After the discovery ether in 1850, surgery was no longer performed without general anesthesia, which was great for anyone who needed an operation. But the gases used to “put people to sleep” are potentially lethal. When used as an anesthetic, the trick is to give them in very small, pre-lethal amounts, while constantly monitoring the patient’s breathing. But mistakes happen, and sometimes anesthetized patients stop breathing and cannot be resuscitated. Statistics published in 1960 for maternal mortality listed “complications of general anesthesia” as the 3^rd leading cause of maternal deaths in the US.

As soon as the nurse-anesthetist announced that the patient was “safely” unconscious, the circulating nurse put the mother’s legs in stirrups, scrubbed her genitals with antiseptic soap, rinsed off the soap with sterile water, dried and painted her crotch with an iodine solution and then covered mother’s unconscious body under a mound of sterile drapes.

At that point the physician came into the delivery room and used scissors to cut an episiotomy on the inert body of the mother-to-be. Then he instructed the circulating L&D nurse to stand on a 12“ stool at the side of the delivery table next to the woman’s pregnant belly so she’s be ready to provide a very forceful and dangerous form of “fundal pressure” in coordination with repeated attempts to pull the baby out of the mother’s anesthetized body with forceps.

 

To accomplish this, L&D nurses were taught to stand on a stool next to the delivery table so they could lean over the mother’s mid-section while balanced on their toes and when directed by the doctor, use their full body weight to push hard with their balled-up fist on the top (i.e. fundus) of the mother contracted uterus in a downward direction to force the baby’s head down into the pelvis, as the doctor pulled from the below with forceps.

 

It was not uncommon for these newborns to suffer a profound respiratory depression and be unable to breath on their own as a consequence of the many injections of narcotics and Twilight Sleep drugs given to its mother during the many hours of labor, the anesthetic gases administered during the “delivery” and physical trauma induced by the combination of forceful fundal pressure provided by the L&D nurse and the brute force required by the doctor to drag the baby out of its mother with the big metal spoons with 12” long handles (i.e. forceps) clamped on each side of its head.

 

We made an initial attempt to resuscitate all of these babies. However, if the baby didn’t “come around” within five or so minutes, which was seen as the limit before brain damage became inevitable, we declared them to be “stillborn”, the idea being that death was kinder to the parents and child than living with profound physical or mental retardation. We wrapped the lifeless little body in a baby blanket and set it aside in the tiny utility room off the delivery room, so its shrouded body could not be seen by the mother in case she regained consciousness and also because it was sad for the nursing staff.

 

The effect of the Twilight Sleep drug scopolamine on labor patients was obvious, but obstetricians and L&D nurses couldn’t see its effect, if any, on the unborn baby. However, when Twilight Sleep was first developed in Germany in 1908 (ck date), they debated the effect of “scopolamine narcosis” on the newborn baby.  Eventually a definitive opinion was sought from a respected professor who concluded that the use of scopolamine was beneficial to the neonate.

“It appears that statistics of the Frauenklinik {German maternity hospital} show that the percentage of infant mortality is low. As against an infant mortality of 16 percent [60 baby deaths per 1,000 births] for the state of Baden [Germany] in the same year, a report on 421 ‘Twilight Sleep’ babies showed a death-rate of 11.6 percent [116 per 1,000 or 36 deaths out of the 421 Twilight Sleep babies or one of every 13 deliveries]

For this strikingly low mortality of the children during and after birth under semi-narcosis, explanation was sought of Professor Ludwig Aschoff, the great German authority on morbid anatomy. He offered the theoretic explanation that slight narcotization of the respiratory organs during birth by extremely minute quantities of scopolamine[e] is advantageous to the child, as it tends to prevent permanent obstruction of the air-passage of children by premature respiration during birth.”

“the tendency to retard respiration on the part of the child may sometimes be beneficial, preventing the infant from inhaling too early, thus minimizing the danger of strangulation from inhalation of fluids.

Editor’s ASIDE: After being an L&D nurse during the Dark Ages of scopolamine and narcotics and the person who give these potentially lethal drugs to mothers who plainly stated they didn’t need or want them, but “doctor’s orders” require that I administer them anyway, and the person that God will hold personally responsible for all those babies that subsequently didn’t breathe, I’m convinced that Twilight Sleep was directly responsible — large and frequently repeated doses of narcotics and scopolamine — for an unconscionably high rate of stillbirths in the hospital L&D units I worked in over a 15 year period of time.

Our Story Resumes:

Irrespective of the newborn baby’s fate, physicians concluded the surgical procedure of “delivery” by manually removing the placenta, which required them to reach a gloved hand and lower forearm into the mother’s vagina and up into her uterus to peel the placenta off the uterine wall with their fingertips and then fold the placenta into their hand and pull it out of the mother’s body.

 

If the baby was live-born, we carried it over to the newborn nursery while the doctor was still busy suturing the episiotomy and probably wouldn’t need us for the next five minutes. Then the unconscious mother was moved by stretcher to her labor bed, where she was monitored by the nurses for the next few hours. This was to make sure she continued to breath spontaneously until she was fully conscious again and also didn’t have a post-birth hemorrhage. Both of these potentially-fatal complications are specific side-effects of administering general anesthesia and the manual removal of the placenta in obstetrical patients.

 

However, there was one more “indignity” that went along with the routine use Twilight Sleep drugs and general anesthesia during childbirth. When these new mothers began to wake from their anesthetic stupor, they always asked “What did I have”? and we’d say: “you had a boy” or “you had a girl”. But a couple minutes later, the mother would again ask: “what did I have?” And we again provided the gender-specific information. This scenario was often repeated a half a dozen times before the mother’s scopolamine-pickled brain was able to remember this important and highly emotional information.

As doctors, nurses, and anesthetists, all of us who were in the delivery room and got to see the baby born and her husband and family relatives got to see the new baby in the hospital nursery. However, the most important person – the mother  – wasn’t able to “be there”. The only person that didn’t get to see her baby born the mother herself and she would be the very last person in her family to meet her own newborn.

This was the most profound
change in childbirth practices in the
history of the human species

It’s impossible for us living in the 21^st century to know all the motives that lead the obstetrical profession in the early 20^th century to publicly denigrate* and systematically obliterate the use of physiologic childbirth practices in hospital obstetrical departments. At the same time, politically influential obstetricians fought ferociously against midwifery training programs and state licensing for midwives who provided *physiologically-based (i.e. non-medical) care for normal childbirth in the family’s home.

This annoyance with and distaste for the normal physiology of childbirth by the obstetrical profession resulted in a famous obstetrician – Dr. J. Whitridge Williams — to complain bitterly and publicly:

“That word ‘physiological‘ has all along stood as a barrier in the way of progress.” Dr. JWW, 1911]

The “progress” Dr. JWW hoped to further was to eliminate the historically normal biology of spontaneous childbirth – mothers giving birth under their own power — with a surgical procedure ‘performed’ by physicians trained in obstetrical surgery. For Dr. JWW, the obstetrical concept of “childbirth” was the result of actions taken by the doctor, and not something done by the mother for herself and her baby.

 

Unfortunately, Dr. JWW eventually eliminated physiological childbirth practices, which he saw as a “barrier” to obstetricalized childbirth. For the first 90 years of 20th century, most America women no longer “gave birth” under their own power, but instead had their baby “delivered” by their doctors. This was especially true when the elective use of Cesareans began to be used in the 1970s to replace normal labor and spontaneous vaginal birth.

 

Typically these new delivered mothers were effusively grateful to their doctors for having “safely delivered my baby”, as if their baby was a packaged delivered by an Amazon employee forced to climb a 5,000 foot mountain in hip-deep snow, forge a fast-moving river in a tippy canoe and then beat a hasty retreat from a grizzly bear before finally arriving, battered, bruised and out-of-breath at the hospital door with the mother’s newborn in his trembling and frost-bitten hands.

 

The wrong use of obstetrics are policies that ignore the well-known dangers associated with the routine use of obstetrical interventions, while simultaneously encouraging and advocating maximum interference under the false flag of “greater safety” and unnecessarily medicalizing normal labor and birth in healthy women with normal pregnancies as the obstetrical standard of care.

 

The wrong use of obstetrics subverts the noble and life-saving discipline of obstetrics (for which we are all grateful!) into a systemized process that routinely causes unnecessary pain and physical harm to both mother and baby. It must be noted that overtreatment is wrong treatment and is every bit as dangerous as undertreatment – both situations fail to meet the actual needs of the childbearing woman and her unborn or newborn baby, often with long-lasting harm and sometimes tragic consequences.

 

The word for this is iatrogenic – harm resulting from the acts or omissions of a medical practitioner.

 

 

 

2. Obstetricians win big but Midwives, Mothers & Newborn Babies loose even bigger!

Having defined childbirth as pathological condition that required a “surgical cure”, midwives, who were neither trained or medically licensed to perform surgery, were eliminated from the American maternity care system. This paved the way for the obstetrical profession to quickly take over and ultimately acquire defacto proprietary rights that identified the obstetrical profession as the sole providers of all childbirth-related services in the United States.

This was helped along by a decades-long PR campaign by the obstetrical profession in newspapers, women’s magazine and the radio. The general public unquestioningly accepted the primacy of obstetrical medicine as evidence of modern scientific progress and vastly improved, much safer care for childbearing women and their babies.

Organized efforts to eliminate the practice of midwives began in earnest in 1910 with the first meeting of the American Association for the Study and Prevention of Infant Mortality (AASPIM) and became more effective during the rest of the 20^th century.

“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. [1915-C; DeLee, MD. p. 114]

The midwife has 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.” Dr. DeLee, 1915-c, p. 114 [emphasis added]

 

The question in my mind is not “what shall we do with the midwife? We are totally indifferent as to what becomes of her…” [1912-B, Dr. JW Williams; p.225]

Relentless as these obstetrical defenders of their childbirth turf were, it still took a couple of decades for midwife-attended births to fall from a national average of 40-50% to just 13%. The vast majority of the 13% were black “granny” midwives in the segregated South where black women were not allowed to give birth in all-white hospitals. But even more disturbing was the steep rise in maternal mortality that tracked exactly with the substitution of non-interventive midwifery care by doctors and midwives with the aggressive use of obstetrical interventions in labor and operative births in healthy women with normal pregnancies.

As mentioned earlier, the top echelon of leaders in the American obstetrical world were acutely aware that the tract record for obstetrically-attended births in the US was abysmal when compared to virtually every other developed country.  In a speech given during a national meeting of obstetricians in 1921 by Dr. Charles Edward Ziegler, MD FACS Professor Obstetrics, University of Pittsburg said:

“Statistics show that during 1913 about 16,00 women died in the US from conditions dependent upon childbirth; that in 1918, about 23,000 women gave their lives in the same way; and that with the 15% increase estimated by [Dr.] Bolt the number during 1921 will exceed 26,000.

Maternal mortality in this country when compared with other countries, notably England, Wales and Sweden, is according to [Dr.] Howard “appallingly high and probably unequaled in modern times in any civilized country”.

While “ignorance is no excuse”, the early 20^th century American obstetrical profession can’t hide behind any supposed ignorance. They knew and they talked about the “appalling high” maternal mortality rate at professional meetings, but many doctors just didn’t want to believe it or didn’t want to make the changes that would have been necessary.

 

~§ 1911 “The story of medical education in the country is not the story of complete success. We have made ourselves the jest of scientists throughout the world by our lack of a uniform standard. [1911-C, p. 207]

~§ 1911 “In 1850, Dr. James P. White, introduced into this country clinical methods of instruction in obstetrics. Yet, during the following 62 years… our medical schools have not succeeded in training their graduates to be safe practitioners of obstetrics.” 1911-B; Dr. Williams; MD

Institutionalizing the ‘Wrong Use’ of Obstetrics

Of those that did believe the really bad numbers, their “solution” was exactly backwards.

Instead of working to exchange the ‘wrong use of obstetrics’ for the “right use of obstetrics”, that is, providing care to women with high-risk pregnancies, treating complications, performing operative deliveries, etc., these leaders believed that all that was ‘wrong’ with the practice of obstetrics could be remedied by providing better training for doctors in the use of forceps, teaching a higher level of expertise in manually peeling the placenta of the interior wall of the anesthetized mother’s uterus and other improvements in their surgical skills.

Editor’s Note: I can’t help but wonder if the frequency and magnitude of complications and mortality that attended the routine use of such a massive amount of obstetrical interventions and invasive procedures did not traumatize obstetrical providers, who mistakenly thought the problem was not enough interventions. In that case the answer was more interventions, earlier in the course of care, and applied even more aggressively. The obstetrical profession become more convinced that midwives and GP were just plain “crazy” to think that physiologic management of CB was ever “safe” under any circumstances.

 

 

 

 

 

 

 

 

3. The Most Influential American Obstetrician in the 20^th Century

One of the most influential contributors to the profession’s decision to profoundly medicalize and hospitalize health childbearing women was Dr. J. Whitridge Williams. He was one of four sons of a wealthy and prominent New England family of doctors and lawyers. Dr. Williams also had the good fortune to be hired by John Hopkins University Hospital in 1893 as a gynecologist surgeon to help set up the new hospital’s gynecological surgery department. He soon moved on to the obstetrical department as a professor.

In the early 1900s he was appointed chief of Johns Hopkins’ department of obstetrics. As the author of “William’s Obstetrics”, his textbook was first published in 1904 and is now in its 25^th edition. In 1911, he arrived at the pinnacle of his medical career after being appointed Dean of the University’s medical school.

At a 1911 meeting of the American Association for the Study and Prevention of Infant Mortality (AASPIM) he commented to the other doctors that:

….. the ideal obstetrician is not a man-midwife, but a broad scientific man, with a surgical training, who is prepared to cope with the most serious clinical responsibilities, and at the same time is interested in extending our field of knowledge.

No longer would we hear physicians say that they cannot understand how an intelligent man can take up obstetrics, which they regard as about as serious an occupation as a terrier dog sitting before a rat hole waiting for the rat to escape. 1911-B

 

In 1912 Dr J. Whitridge Williams bragged to physician-members of the 1912 meeting of the AASPIM that childbirth:

 

“…[childbirth] was now in intelligent circles a surgical procedure” to be performed by physicians with training in obstetrical surgery

 

“In Johns Hopkins Hospital,” said Dr Williams, “no patient is conscious when she is delivered of a child. She is oblivious, under the influence of chloroform or ether.

… every patient who goes to the hospital may have full assurance that she will pass through what would otherwise be a dreaded ordeal in a state of blissful unconsciousness.

In 1914 Dr. Williams published “Twilight Sleep: Simple Discoveries in Painless Childbirth”.

As the title clearly states, Dr. Williams’ book was about childbirth (chapters 1-4). However, women were not its intended audience. Instead Dr. JWW’s message was targeted at wealthy philanthropists, politically influential men and economically-advantaged husbands (chapters 5-8).

His book begins by referring to “the sacred function of maternity” as something that causes childbearing women “months of illness and hours of agony”. His basic vocabulary for describing normal childbirth included:

• acute suffering, agonies of childbirth, agonies of tortured humanity, dangerous ordeal of motherhood, dreaded ordeal, her suffering sisters, terror, useless suffering

His more colorful descriptions include:

• the shock that ordinarily attends the ordeal of childbirth
• pain needlessly suffered by the mothers of the race in carrying out their essential function of motherhood
• women bring forth their children in sorrow, … unsolaced by even single whiff of the beneficent anesthetic vapors
• civilized women of the most highly developed nervous or intellectual type who suffer most, the most intense pain to which a human be can be subjected
• the evils incident to the performance of her supreme function

The Invention of a Pathological Pain Syndrome affecting middle- and upper-class Women

As related in his 1914 book, Dr. Williams reported that the pain of normal uterine contractions in the more affluent classes of women had recently been identified by him as pathology, a situation he ascribed to the negative effects of modern civilization on the evolutionary process. According to him, only cultured and sensitive women from middle and upper-class families were at risk for unbearable labor pains so severe that these women could literally be driven crazy by labor pains.

 

The adjectives Dr. JWW used to identify this unfortunate cohort of women included: civilized, cultured, intelligent, sensitive, delicate. Unfortunate for us, his book never defines the characteristic he called ‘delicate’, but he was specifically referring to educated, intellectually and socially astute and economically-secure white women from the middle- and upper-classes.

He specifically excluded immigrants, ethnic minorities and poor women working, a category he negatively identifies as robust and “nerveless”, making very clear that his pathological pain syndrome only applied to stay-at-home married women and mothers with husbands employed full time or independently wealthy and whose delicate and nervous wives are the polar opposite of those “robust” “nerveless” immigrant and poor working women.

Dr. JWW is convinced that this pathological pain syndrome is caused by an evolutionary fluke and cites Darwin’s theories of evolution as support for this syndrome’s origins and nature and ultimately what should be done about it. He began by explaining that:

“…… any trait or habit may be directly detrimental to the individual and to the race and may be preserved, generation after generation, through the fostering influence of the hot-house conditions of civilized existence.

Then he tells his readers that the laws of Darwinian evolution — the idea that Nature naturally selects for success and betterment of each species:

“does not fully apply to human beings living under the artificial conditions of civilization”.

With this in mind, he describes these pathological labor pains as an “abnormal product of civilization” that, for unexplained reasons, is the result of the “hot house conditions of civilization”, and only affects the type of women that Dr. JWW describes as “civilized, cultured, delicately-organized and intellectual”.

“Is there not fair warrant for the assumption that the pains which civilized women—and in particular the most delicately organized women — suffer in childbirth may be classed in this category?

I believe the answer must be an unqualified affirmative. Considered from an evolutionary standpoint, the pains of labor appear not only uncalled for, but positively menacing to the race.”

“The problem of making child-bearing a less hazardous ordeal and a far less painful one for these nervous and sensitive women is a problem that concerns not merely the women themselves, but the coming generations.

Let the robust, phlegmatic, nerveless woman continue to have her children without seeking the solace of narcotics or the special attendance of expert obstetricians, if she prefers.  But let her not stand in the way of securing such solace and safety for her more sensitive sisters.”

In further describing the pathology of labor pain and its effects in the cohort of “civilized” and “cultured” women who are victims of evolution, Dr. JWW noted that:

“women of primitive and barbaric tribes appear to suffer comparatively little in labor, coupled with the fact that it is civilized women of the most highly developed nervous or intellectual type who suffer most” {p. 39}

“…. the cultured woman of to-day has a nervous system that makes her far more susceptible to pain and to resultant shock than was her more lethargical ancestors of remote generations.”

“such cultured women are precisely the individuals who should propagate the species and thus promote the interests of the race “

‘This seems to suggest that the excessive pains of childbirth are not a strictly a ‘natural’ concomitant of motherhood, but rather that they are an extraneous, and in a sense, an abnormal product of civilization.”

“Is there not fair warrant for the assumption that the pains which civilized women—and in particular the most delicately organized women – suffer in childbirth may be classed in this category?

Since these “civilized” women were being treated so unfairly by Mother Nature, Dr. JWW believed: doctors should treat

“…the agonies of tortured humanity” with “the waters of forgetfulness {page 10}

According to Dr. JWW’s “labor pain as a pathology” theory, healthy middle- and upper classes women were not getting the medical and surgical interventions they obviously needed and deserved. This put them in danger of a mental breakdown that would require them to be committed to a psychiatric institution. To prevent this, Dr JWW believed these women should be electively hospitalized and given Twilight sleep drugs during labor and general anesthesia for the birth.

Dr. JWW apparently assumed people would not question the correlation between a woman’s supposedly “nervous” or “delicate” condition and the economically-advantaged status her family. As a former obstetrical professor and chief of the obstetrics at Johns Hopkins University Hospital and Dean of the University’s School of Medicine, readers assumed that Dr. Williams was speaking authoritatively from his professional experience and his ‘insider information’ was beyond question – right from God’s lips to your ears!

 

As a result, no one questioned his claim that the only cohort of childbearing women who suffered a “pathological levels” of pain associated with an otherwise normal labor were those whose husbands could afford to pay, in addition to the physician’s professional fee, a substantial bill for hospital labor and birth and 14 days of hospital lying-in care for the new mother and 14 days of hospital nursery care for her new baby.

 

Dr. William’s message to Husbands

 

A number of passages in of Dr. JWW’s book that are specifically aimed at middle- and upper-class husbands. He describes the “shock” of labor that specifically affected these sensitive, delicate and intellectual women as being so sever as to cause some newly delivered mother to suffer an acute mental break down that require her to be institutionalized for weeks or months or even longer.

I imagine that most husbands think of their wives as having at least one of these desirable feminine traits, so the idea that a normal labor could cause their sensitive or delicate wife to have a mental breakdown must have been “shocking” to these concerned but medically-unsophisticated husbands.

Mixed Motives or Hidden Agenda?

There is something of an unspoken challenge in providing this kind of inflammatory information to a lay audience of husbands and fathers. It’s as if the subtext of Dr. JWW comments are asking husbands they really want to take the chance that their wife, and mother of their children, would suffer a mental breakdown and be locked away in a psychiatric ward for weeks or months while they are left to care for several older children and a newborn infant while also trying to support their families.

After giving husbands a made-up reason to be afraid, really afraid, Dr. JWW gave them the really good news — all they had to do was take their delicate and/or intelligent wife to the hospital as soon as she went into labor. Once hospitalized, she would be given morphine and scopolamine and never feel or remember anything until long after the baby was born. Her mental facilities, as a matter of course, would be protected by the use of Twilight Sleep drugs and rendering his wife unconscious with general anesthesia.

Bada bing, bada boom, problem solved!

Eugenics ~ Dr. JWW’s concern about the changing demographics of the United States

Dr. Williams’ focus on the propagation of “the species” grew out of his concerned that white women of northern European heritage were having too few babies, while black and brown populations and new immigrants were having far too many babies. He thought that making childbirth painless for the more affluent classes would convince white women to have more babies, a sentiment that aligned with his desire to see Caucasian Europeans “propagate the species and promote the interests of the race“, in order to preserve the country’s white majority and European culture.

As someone who has a family and is familiar with childbearing families, I can tell you that what Dr. JWW thought was all wrong.  Neither Twilight Sleep drugs or general anesthesia would ever make any woman have more babies, because “real mothers” know that the “real labor” of childbearing begins when you have to get up half-a-dozen times a night to breastfeed a colicky baby and standing over a hot stove cooking for half-dozen hungry kids or washing and ironing mountains of family laundry.

Apparently, Dr. JWW didn’t factor in the reality of the situation. After you have one of more of those white babies, you had to feed, clothe, educate and raise them! I suppose if you were the creme de la crème of the upper class and in addition to your regular housekeeper your wealthy husband hired a bevy of round-the-clock lying-in nurses, a laundress to do diapers and the household washing and ironing, as well as a cook, having more babies as a patriotic duty to one’s country might possibly be an OK thing to do with your body for nine months out of every year. However, not even Elenore Roosevelt, mother of six and wife of the US president, had an easy time of it and god know, she had a lot of domestic helpers.

And for women in the bottom half of the upper-class and the entire economic spectrum of the middle-classes, Dr. JWW would have much better chance selling snake oil to them than the ludicrous idea that hours of memory loss under Twilight Sleep narcotics and amnesia drugs, as well as drowning “the agonies of tortured humanity in the waters of forgetfulness” would make up for having to raise another baby. Let’s face it, the hallucinogenic drug scopolamine does not have any mysterious or lingering aphrodisiac effect associated with it.

After you give birth, you “have a baby”, like after you buy a car you “have a car” — you are your baby’s mother and you are fully responsible for meeting the entirety of its needs for the next 18 or so years. Nothing in Dr JWW’s elective-hospitalization and lying-in-wards ‘scheme’ was designed to help these new mothers manage the gargantuan, 24-7-365 job of raising their newborns after the drugs wore off and they left the hospital with their new baby.

However, convincing well-off white women to have more babies was not actually Dr. William’s primary goal in writing Twilight Sleep.

The real purpose of his book – the idea behind it all — was to introduce and develop support for Dr. JWW’s plan for a nation-wide system of general hospitals. He envisioned a coast-to-coast network of full-service general hospitals equipped to provide the same comprehensive, 20th-century state-of-the-art medical services — in quality if not quantity — that patients received in the general hospitals of Western European countries and his own alma mater, Johns Hopkins University Hospital in Baltimore, Maryland.

 

A nationwide system of general hospitals was Dr. JWW’s dream, his passion, his true love. His plan was to somehow convince the doctors who owned those thousands of tiny 2-10 bed hospitals sprinkled all across the landscapes and frontier towns of America to develop new lying-in wards and electively hospitalize affluent maternity patients as paying customers as a fund-raising scheme for privately financing a new system of general hospitals to rival those of Europe!

 

 

 

 

4. Dr J. Whitridge Williams’ Dreams, Motives and Methods

 

Dr. JWW’s personal dream and professional goal was figuring out how to finance a system of acute-care general hospitals in the US that were equipped to treat all types of illness and accidents in all ages and stages of life.

 

Western European countries already had a national system of general hospitals developed over several centuries. These well-staffed regional hospitals were able to provide comprehensive medical services to their entire population, no matter where the patients lived, regardless of their ability to pay and irrespective of the kind of care they needed — surgery, orthopedics, obstetrics, pediatrics and emergency care for acute illness, accidents and life-threatening injuries.

By contrast, the United States had, by best estimate {note-2-self – can’t find original source}, about 8,000 private hospitals owned and run by one or two local doctors. Aside from electric lights and a telephone, most of these 2-to-10 beds hospitals were so small they couldn’t afford the emerging medical technologies of their day, such as the new x-ray machines invented in 1895, clinical laboratory equipment and new surgical suites with easy-to-disinfect ceramic-tilled walls and bright spot lights over the operating room table.

As a strict business model, the services of these small private hospitals were only available to those who could afford to pay up front. They also didn’t provide any emergency services to the general public. This was partly due to their for-profit status and partly because they didn’t have a 24-hr staff or the necessary emergency equipment. With the exception of minor surgeries, these hospitals were more akin to convalescent homes or TB sanitoriums than the regional system of highly-equipped and fully-staffed general hospitals in Europe that so impressed Dr. JWW and were so sorely needed in the US.

In contrast to thousands of these one-room, ten-bed hospitals, the US only had about two dozen general hospitals in the entire country, most of which were in large metropolitan areas on the East and West coasts, and Chicago, New Orleans and Denver. For the great majority of Americans, the nearest general hospital was often a couple hundred miles away in another state. Badly injured farmers who lived in rural parts of the state, babies in convulsions from a high fever, mothers in an obstructed labor and husbands having a heart attack would suffer terribly or even die while their families were trying to get them to the closest general hospital. As far as Dr. JWW was concerned, this was no way to provide science-based, state-of-the-art medical care to the American public and the rest of us would agree with him.

At the time he wrote Twilight Sleep, Dr. Williams had worked for more than twenty years in what was probably the very best general hospital in the US – Johns Hopkins University Hospital in Baltimore, Maryland; he had an intimate understanding of the difference between the European and the US systems. Soon after Dr. Williams graduated from medical school, he sailed to Europe for two years of clinical training. During that time, he studied obstetrics and pathology in some of the best general hospitals on the European Continent, and also experienced for himself their comprehensive and well-coordinated general hospital systems.

As a doctor at Johns Hopkins, he cared for plenty of patients that would have needlessly suffered agonizing pain for many hours or days, become permanently disabled and unable to work, or died had they not had access to the speedy and comprehensive medical services provided by a general hospital like Johns Hopkins. In contrasted with the efficient and effective general hospitals of Europe, he was only too aware that our disorganized American system failed to meet the most basic medical needs of its citizens.

Dr. JWW’s Two-part Plan for funding a nationwide system of General Hospitals

There was no doubt in Dr. JWW’s mind as to what was needed – a system of general hospitals to match (and hopefully exceed!) those of Europe. But unlike the nationalized systems on the European Continent, general hospitals in the US could not depend on government funding but instead would have to be part of a private, for-profit system. That made money, money, money the big issue in the US – how to find or create a revenue stream that organized medicine would not fight against tooth and nail. Dr. JWW knew the slightest whiff of federal funding would automatically bring the considerable wrath of the American Medical Association down on his head.

The AMA was fiercely protective of the “entrepreneurial” endeavors of medical doctors while being bitterly opposed to anything that smacked of “government interference”. Its leaders characterized any government involvement, including federal financing, as the dreaded “socialized medicine” which they said threatened the “sacred doctor-patient relationship”. For the AMA this issue was non-negotiable and Dr. JWW knew they weren’t going to change their minds any time soon. There was no doubt that government funding would be the kiss of death to his entire Plan.

Mission Impossible: Finance general hospitals without triggering AMA opposition

The historical opposition of organized medicine in the US put Dr. JWW back to square one: How to finance hundreds of privately-owned general hospitals, and once up and running, how to keep them in the black for the next couple of decades? But something about this impossibly tall order apparently inspired him. As someone that had successfully climbed many metaphoric mountains during his career, it may have been the weight of suffering humanity, or perhaps the lure of such a magnificently challenging problem, like playing chess with a world-famous Grand Master after he’s captured your queen. Maybe he just saw it as his patriotic duty. Whatever the motivation, stakes were sky-high, but the prize was even higher!

 

As a visionary, Dr. JWW’s was simultaneously bold and undeterred and did not give up or give in when faced with multiple and apparently insurmountable barriers.  His plans for financing a general hospital system were truly extraordinary for their scope, ingenuity and multi-layer complexity. This began with a frankly audacious two-part plan that historically would knock the ball out of the park. His grand prize was the steady development of a nationwide system — sea to shining sea, Canada to Mexico — of general hospitals. Within a two or three decades, Americans that didn’t live in or near a few big cities need not suffer or die needlessly from a medical emergency because a general hospital was not with reasonable driving distance!

 

But without this new system, the picture would continue to be grim. For decades to come many millions of Americans would be doomed to unnecessary pain, suffer preventable life-long disabilities that turned healthy husbands and fathers into crippled beggars while their wives and children starved, and uncountable numbers of needless deaths – all because the US, unlike other industrialized countries around the world, wasn’t able to provide essential medical services to his own population. Dr. JWW knew his plan could change all this.

Part One ~ Inventing a new and guaranteed-profitable business model for America’s private hospitals by introducing the idea of elective hospitalization & targeting affluent maternity patients as their first paying customers

Dr. J. Whitridge Williams Plan was a remarkable undertaking with lots of moving parts, so I’ll begin where he began, which was inventing the economic engine that first created and now maintains America’s private, for-profit, mostly corporately-owned hospital system.

With the goal of creating a guaranteed-profitable business model for hospitals, Dr. Williams’ configured the economic aspects of his Plan to produce a remarkably successful and first-of-its-kind financial scheme. In a pre-insurance and pre-federal Medicare-Medicaid era, he reconfigured the traditionally undependable business model of private hospitals by allowing private hospitals to use the same economic principles for running a profitable business that were already being successfully used by the rest of the commercial world.

 

As a general principle, this describes looking at every monetary transaction thru a cost-profit lens when making decisions. If an essential service provided by your business wasn’t paying its own way, you had to figure out how to off-set these losses by branching out in different area that would generate enough additional revenue to make up for these loses, and whenever possible, provide a handsome profit.

 

American hospitals stuck with an outdated 19^th century business model

 

Prior to this, private hospitals in America were trapped between the Devil and deep blue sea. In order to keep the lights on and pay their staff, they absolutely had to make a profit, but in the early 1900s public sentiments and the medical profession itself expected hospitals to be economically–passive, that is, not to blow their own horn by publicly “marketing” their services or do anything directly related to making money, which was seen as unprofessional and unseemly. Advertising to increase the daily patient-census was verboten, as was offering profitable outpatient services such as x-rays, blood tests or same-day surgery. They also had not yet figured out how to provide very popular and profitable convenience services, such as more expensive private rooms, hospital gift shops, coffee shops, staff and hospital visitor cafeterias, valet parking or parking garages that charged by the hour.

 

Not only did private hospitals have to deal with policy barriers, but often found themselves bleeding red ink after they paid the salaries of the physician-partners that owned and ran them and monthly bills for heat, lights, water, telephones, nurses, cooks, groceries, other kitchen helpers, several laundresses, building maintenance, necessary medical supplies, replacing a broken hospital bed, etc, etc. Hospitals were also reluctant to forcibly discharge chronically ill or dying patients who could no longer pay their hospital bills for fear of losing the good will of the public which they so depended on.

 

In most other developed countries, the cost of building and expense of running hospitals was funded the same way as public schools, libraries, police & fire departments, roads, the military, which was to collect small sums in the way of taxes from a huge number of essentially healthy working people. But that was not to be in the United states, which left the majority of our small private hospitals economically trapped in the non-technological world of 19^th century medicine.

 

This is where Dr. J. Whitridge Williams steps back into the story.

 

Dr. J. Whitridge Williams had a “Plan” that not only would stop hospitals from hemorrhaging red ink but would for the first time put the “business” plan of private hospitals on the same firm footing as other for-profit businesses. Best of all, they wouldn’t need to trudge off, hat in hand, to their local bank to beg for a big loan so they could to make themselves into a far more profitable business that could better serve their community.

 

Dr. JWW imagined, fervently hoped and ultimately succeed in implementing a “Plan” for privately generating many millions of dollars (today it would be billions) needed to upgrade, remodel and slowly expand existing hospitals. By implementing these ideas over a 5, 10 or 20-year trajectory, a significate number of small and medium-sized American hospitals used the profits from their lying-in ward to become well-equipped, fully-staffed general hospitals able to provide comprehensive medical and surgical services to their surrounding communities. This all happened without being forced to find investors or qualify for bank loans or pissing off the AMA.

 

Here is how Dr. Williams’ was able to pull this rascally rabbit out of his hat!

 

Part One: The assured-profitable of Dr. JWW’s economic model for hospitals started with and depended on his invention of a brand-new category of hospital patient – the electively hospitalized healthy patient as a paying customer. His first choice for this new category of profitable patient was the elective hospitalization of healthy maternity patients. The targeted demographic was middle- and upper-class (obviously white) women whose families could pay upfront. The unique “comforts” he offered in return, “comforts” only available to hospitalized labor patients, was the “pain-annulling” drug-combination known as Twilight Sleep (narcotics and scopolamine) during labor and “anesthetizing the patient with chloroform” for the surgically-conducted “delivery”.

 

Dr. JWW’s two-part plan to electively hospitalized maternity patients as paying customers was at the core of a fund-raising scheme designed to transfer wealth from affluent maternity patients to private lying-in hospitals or slightly larger hospitals that had already had lying-in wards or recently added one. These hospitals would then use the profits generated by their lying-in services to remodel, upgrade, expand their hospital facilities. Many but not all would eventually become one of the many new general hospitals that provided the United States with a nationwide system of comprehensive hospital services.

 

Part Two: In order to bring this about, Dr. JWW’s Plan officially promoted the idea that small 2-10 bed hospitals re-brand themselves as dedicated “lying-in” hospitals. Medium and larger hospitals were advised to add a lying-in ward included a private room for the labor and birth, a ward for postpartum beds and nursery for newborn babies.

 

The obstetrical profession’s PR campaign in newspapers, women’s magazines and radio programs assured the “modern” woman that the new and much better way to give birth the 20^th century was in a hospital, followed by a 14-day “lying-in” period so the new mother to rest and regain her strength under the watchful care of postpartum nurses while her newborn in the safe hands of the nurses that staffed the hospital nursery.

 

Dr. JWW’s Plan for hospital maternity wards was designed to put midwives and general practice physicians who attended births in the family’s home or the doctor’s office out of business while constantly increasing the rate of hospital births.

 

Maternity Patients as Paying Customers ~ Lynchpin of Dr. JWW’s plan for General hospitals

 

Financing for every other aspect of Dr. JWW’s enormous, multi-generational plan was totally dependent on childbearing women voluntarily patronizing these new lying-in hospitals and wards as paying customers.  Without realizing it, this class of maternity-patient-as-paying-customer was the most critical element of Dr. JWW’s plan – the foundation and load-bearing-walls upon which the funding of the new general hospital system depended. Dr. JWW and all the private owners of hospitals knew all too well that without sufficient patronage of stand-alone lying-in hospitals, and lying-in wards in medium-sized hospitals, their whole plan would go down in flames.

 

If that happened, the only other option would be the dreaded public (i.e. government) funding, but the AMA would never stand for that, so the US would be saddled with an outmoded hospital system for generations to come, as well as being the laughingstock of all the other industrialized countries.

 

Clinical Training for Medial Students an Important aspect of a general hospital system

 

Any failure in Dr JWW’s plan for funding a nationwide system of general hospitals also meant that medical school would not be able to provide the all-important clinical training programs to their students. Supervised clinical training in acute-care hospitals was a vital aspect of medical education that was especially important for surgical specialties like obstetrics. Well-supervised clinical training also could mean the difference between life and deaths for patients, as one could as easily die from incompetent medical care as from not having access to desperately-need hospital services.

 

Without a nationwide system of general hospitals such as existed in Europe, most medical schools in the US we not able to provide adequate clinical training. Even today, access to sufficient clinical training puts a lid on how many students medical schools can enroll. Medical students need dependable access to high-volume patient wards that can provide students with opportunities to recognize the symptoms of uncommon diseases, hone their diagnostic abilities, develop technical skills such as palpating body organs, listening to hearts and lungs, suture lacerations, performing minor surgeries or using obstetrical forceps under the watchful eye of a clinical professor.

 

Doctors graduating without this hands-on experience only had two choices. If lucky enough to come from a wealthy family, they just traveled to Europe and enrolled in a clinical training program in one of Europe’s regional hospitals. Unfortunately, less well-off new graduate MDs would have to piece together their clinical skills as “on-the-job-training” after they opened their own private practice.

 

However, every medical school dean and every professor of obstetrics knew how dangerous it was to be the patient of a doctor who was still in the “on-the-job-training” phase for learning clinical skills. Medical educators knew that top-tier medical education was impossible without universal access to hospital-based clinical training as a part of every medical student’s education.  This obviously required a nationwide system of general hospitals.

 

 

Fruit of the Poison Tree: One Big Black Lie & bevy of Half-truths

 

When cornered between a rock and a hard-place, good people can do desperate things. Clearly Dr. JWW was driven to do whatever was needed to achieve this goal of a nationwide system of general hospitals, even if it meant inventing a ‘creative spin’ that began with one very big, very black lie, a host of half-truths, and lots of white lies to cover up these really inconvenient truths.

 

Dr. JWW’s big lie was the convenient story about the “hot house of civilization” resulting in an evolutionary fluke that only affected middle- and upper-class women and made labor into a pathological process that required elective hospitalization, Twilight Sleep drugs, and a “delivery” that consisted of a series of surgical procedures – episiotomy, dangerously forceful fundal pressure, forceps and other invasive procedures performed on an anesthetized mother.

 

According to Dr. JWW, this better-off demographic of middle and upper-class women had families that, by some happy accident, could afford a substantial hospital bill for the services of L&D nurses and series of surgical procedures that Dr. Williams and many other obstetricians said were absolutely necessary to “safely” extract a baby from the inert and unconscious body of its mother.

 

Dr. JWW was obviously blind to his own prevarications and thought primarily of how things either did or didn’t contribute to his self-funding system for growing small hospitals into larger general hospitals.  Perhaps he thought: “If I’m successful, the women I lied to will still be perfectly OK.” Like most other obstetricians, Dr. JWW was thoroughly convinced that hospital birth with an obstetrician was so much better than a home birth with a midwife or backwoods doctor. Surely there wasn’t anything wrong with tricking these women into being electively hospitalized and providing then with the ‘comforts’ of “pain-annulling drugs” and “anesthetizing the patient with chloroform”.

 

Viewed from his perspective, the financial contributions of these affluent families were a critical part of a far-reaching humanitarian effort specifically developed to provide US with the same first-rate hospital system enjoyed by countries all over western Europe.  This prize was so big, and it affected every American who didn’t live within reasonable driving distance of a general hospital. Surely the good it would bring to society would excuse Dr. JWW for play a little loose with the truth.

 

The good doctor himself remarked that men would benefit from the profitable hospitalization of healthy lying-in patients that provide, since that system provided the money for hospitals to branch  out and serve other types of patients and other forms of care that would eventually benefit men of all ages, infants and children and the elderly as the hospital’s services became more comprehensive.

 

The economically critical issue that everything else hung on was successfully convincing each pregnant woman, her husband and the rest of her family that:

 

• It is was no longer safe or appropriate for a woman to labor in the comfort and familiarity of her own home surrounded by her family and close friends

 

• To eschew the intergenerational tradition of being attended by a midwife that the childbearing woman personally knew and trusted to to see her through the labor and birth of her baby in her own home while surrounded by family and friends

 

• Have her husband drive many miles, often in the middle of the night, to take her to the hospital when she went into labor, kiss her goodbye at the Labor Room door, drive back home in the dark and wait for the hospital to call to tell him the baby was born, it’s a boy (or a girl) and his wife is alright but he can’t see her because she is still unconscious from the anesthesia

 

• Get her husbandto agree to pay the much more expensive bill (compared to midwifery care) for a hospital birth and the 14-day lying-in period for mother and baby.

 

It should be noted families didn’t have to pay a hospital bill for the traditional 14 days “lying-in” period when the new mother was at home in her own bed, attended by family and friends who helped to care for her newborn baby. Under these more ‘normal’ circumstances, the family also avoided the problems that frequently plagued hospital nurseries, such as infections and cross-contamination, mixing up babies, or improper sterilization of baby bottles and other supplies.

 

But Dr. Williams only concern with these issues was how best to eliminate all non-hospital maternity services.  His book was the blueprint for a public relations that capitalized on his Big Lie while trashing all providers of midwifery care (doctors as well as midwives) and promoting hospital birth as the ‘new norm’ and only “appropriate” place for well-off women to give birth. But from a PR perspective it was still an uphill journey, as it was not until 1938 that over 50% of births occurred in a hospital and 1969 before more that 99% of babies were delivered in hospitals.

 

The practice of medicine before women had the right to vote. 

 

It’s useful to take into account Dr. JWW’s stratospheric social status into account. He was a wealthy, upper-crust, university-educated, socially and politically influential white male medical doctor in a very patriarchal, chauvinist, classist, sexist, and racist society. This is not a personal criticism of him as an individual, just an observation of the facts as they applied to this era of American history.

 

While I don’t claim to know Dr. Williams personal thoughts, I have read, re-read and studied hundreds of documents by and about Dr. JWW’s life and his contemporary world over the 40-plus years I’ve studied the universal practices of traditional midwifery and obstetrical practices of American obstetricians. I believe I can, to some extent, surmise his personal feeling based on the big picture of his life, which in general was highly ethical and leads me to surmise how he felt about his high-stakes plan for a much-needed general hospital system. For him failure to provide, via an effective funding scheme, a nationwide general hospital system was just unthinkable, something he couldn’t let happen.

 

Much of what Dr. JWW said in his book about women and about childbirth was filtered thru the lens of that list of “-isms”, particularly his patriarchal chauvinism and misogyny. These ideas were simply not true, but unfortunately for American women, male physicians acted on them as if they were the “God’s awful truth”.

 

In 1914, women did not have the right to vote, which officially gave men the right to decide what was best for them, without asking their opinion or permission, and against their voiced objections.  The consensus among obstetricians of this era was that women didn’t have any important information or insights when it came to childbirth anymore that family pets and farm animals had “knowledge” of their reproductive biology. The American obstetrical profession firmly believed the rightful role of their surgical specialty of obstetrics and gynecology was as gatekeeper over the reproductive lives of women, with total control over childbirth-related services of any and all kinds.

 

However, he described the hospitalization of these laboring women as providing “comforts” that the childbearing woman herself in real life would experience as uncomfortable in the extreme:

 

“These comforts, it must be borne in mind, include the use of pain-annulling drugs. In this country, it is customary to anesthetize the patient with chloroform, though some competent practitioners prefer ether.

 

We have already seen that the merits of the morphine-scopolamine treatment, inducing the Twilight Sleep, are to be fully tested at the Johns Hopkins Hospital”

 

Personally, I wish Dr, JWW could have risen above the “isms” and other prejudices of his day that objectified childbearing women in a very unfavorable light. But in the last frame, he either couldn’t or wouldn’t, we will never know which.

The “Business” of Hospitals and Influence of the AMA

As a visionary, Dr. JWW’s was simultaneously bold and undeterred.  His plans for financing a general hospital system were truly extraordinary for their scope, ingenuity and complexity.

As noted above, Part one of Dr JWW’s “scheme” began with his invention of an all new business model for acute-care hospitals that assured profitability, the key being a new category of hospital ‘patient’ as the electively hospitalized paying customer. It was not lost on Dr. Williams that depending totally on sick people to pay their hospital bills was a failed business model. Basically, the chronically ill and seriously injured are also chronically poor because they can’t work. As a category, the ill and injured, as well as infants, small children and the elderly, have always and will always be the world’s very worst demographic for any kind of profit-making business to depend on.

This is why institutions in Western Europe that provided “hospitality” services (origin of the word “hospital”) was a free service that included a dry bed, clean sheets, nutritious meals, changing bandages and emptying bedpans for the sickest of the sick who were also the poorest of the poor. Historically, a vast number of these institutions were in Western Europe, and were funded and run by the Catholic Church (or occasionally a state government) and staffed by nuns and monks.

One of the very first such hospitals was founded in 369 CE by Catholic Saint Basil of Caesrea, who was a pioneer in establishing hospitalization and care for the sick and disabled. However, most famous and far-reaching of charity hospitals was started in 613 CE by the bishop of Paris (later to become St. Landry) on the banks of the river Seine. This hospital was, and still is, called Hotel de Dieu, still situated on the Seine and is still treating patients. This begin the Western European tradition of charity hospitals funded by the Roman Catholic Church and operated by religious orders as part of their humanitarian vocation to provide free services to the poor.

While these much-needed services were free, none of us would want to go back to these “good old days” which actually were pretty bad. While having a dry bed with clean sheets as mentioned above seems very attractive, many of these (obviously) very big beds were routinely occupied by as many as six patients laying head-to-foot in alternative rows! Such patients were lucky if they didn’t get bedbugs!    

Back to the Future of American Hospitals

This brings us back the economic realities of early 20^th century America, whose thousands of small hospitals were definitely were not run as charities. While religious, civic and social organizations and local governments sometimes ran a hit-or-miss system of charity hospitals, these hospitals were primarily in high-density population centers and not available to people living in small towns and rural farming communities. At the same time, proprietary ownership of hospitals in the US was seen by organized medicine as the bedrock a private entrepreneurial system, one that was fiercely and aggressively protected by the AMA.

Doctors or groups of doctors owned and ran medical clinics and hospitals the way entrepreneurial farmers, or a farmers’ co-op, might own and run a small vegetable stand that grew into a medium-sized grocery store that was so successful these farmers wound up owning a franchise for a chain of grocery-related businesses, thus becoming a beacon and guiding light for American enterprise.  For doctors, being an entrepreneur was the same process of owning and running clinics and hospitals. Doctors, as represented by the AMA, were convinced that as American citizens in a democratic society, exercise of free-enterprise was their constitutional right and any government interference was downright un-American, hence the eternal and impenetrable opposition of their union.

Given the substantial limitations imposed by organized medicine, it comes as no surprise that Dr. JWW’s first choice for the new category of elective hospitalized paying customers was (obviously) healthy middle and upper-class maternity patients. With an annual birth rate in the US of two million-plus babies, any maternity-related service was obviously a potential gold mine for private hospitals.

 

 

 

 

 

 

 

 

 

 

4. Part Two – Economics of Lying-in Wards – the Hospital Business on Steroids  

Part two of Dr. JWW’s Plan was to convince the doctors who owned thousands of those little 2-10 bed private hospitals sprinkled in small towns all across American to rebrand themselves as dedicated “lying-in” hospitals, while Dr. JWW aggressively encouraged medium-sized and larger hospitals to add a new lying-in ward by remodeling some “empty room” or other “unused portion of the building” or even building a new wing for their lying-in department.

Dr. JWW calculated the annual birth rate for the average county in the US to be 700 babies a year. He remarked that if they could convince just half of those 700 pregnant women – just 350 — to give birth in their local lying-in hospital – would provide an average patronage of one delivery every day.

Given the nature of pregnancy and childbirth, all maternity patients can be counted on to do something no other type of hospital patient could ever do, something that we’d think was science fiction if it weren’t such an immutable biological fact, and that is to produce another hospital patient – a newly-born miniature human being to be admitted to the hospital’s newborn nursery and billed accordingly. The annual patronage of the hospital’s maternity ward by 350 new mothers as paying customers would generate revenue for a combined total of 700 maternity-related hospital admissions each year.

And unlike hospitalizations for acute illness, which is often seasonal, or serious injuries which are unpredictable, childbearing women give birth all year round — 365 days a year, rain or shine. However, hospital maternity patients were billed the same daily room rate as other hospital patients, even though maternity patients and their healthy newborns rarely needed or used the hospital’s acute-care resources, which were so much more expensive for the hospital to provide. This cost-disparity so favored maternity wards that they quickly became the hospital’s cash cow.

A Marriage Made in Heaven ~ Pregnant women and hospital maternity wards

According to Dr. JWW’s Plan, when better-off healthy maternity patients went into labor, they would be driven to the hospital by their husbands and admitted to a labor ward. After giving birth, new mothers were admitted to the postpartum ward and their new babies admitted to the newborn nursery. Each new mother and her healthy newborn would remain hospitalized for the traditional 14-day “lying-in period”. Even better news for hospitals was how cheap it was to provide maternity care to a cohort of healthy, relatively well-off women and their newborn babies.

What made Dr. JWW’s financial elective-hospitalization “scheme” so dependably profitable was that healthy childbearing women aren’t really “patients”, in the since of being sick or disabled. Seriously ill or injured hospital patients required time-consuming nursing care, medical and surgical procedures and other extensive or expensive hospital services and sometimes died without paying their hospital bills. Compared to hospital care for critically ill or injured patients, maternity services were very profitable.

The needs of these new mothers were typically more in the category of hospitality services as provided by a nice hotel for maternity patients — dry bed, clean linens, fresh bedside water pitcher, hot meals and breastfeeding tips for first-time mothers. As for the care required by healthy newborns, the new mothers themselves could be counted on to breastfeed their new infants, change diapers and comfort them when they cried.

When viewed from the “bottom line”, hospital owners and administrators quickly realized that hospitalizing healthy people were much more profitable than acutely ill or injured patients. When calculated on an annual basis, the average 14 days hospitalization for 350 lying-in patients and their newborns came to an astounding 9,800 patient-days — 350 new mothers and 350 newborns with combined 28 patient-days – and families billed the hospital’s daily room rate for each day of hospitalization.

 

With such dependable profitability, hospitals could count on their lying-in wards to generate a steady revenue stream that made up for financial losses in other departments of the hospital. Even more exciting, this profitable income paid for gradually upgrading and expanding their facility. It’s safe bet that more than one hospital administrator saw hospitalized pregnant women as the answer to their prayers.

In addition to money for hospitals to upgrade their facilities, income from maternity services also allowed smaller hospitals to purchase new capital-intensive medical equipment such as x-ray machines, institutional autoclaves, better operating room tables and new bright overhead spot lights in the OR.

Gold Medal for Labor Day ~ for childbearing women or for the hospital?

It seems that the “labor” of laboring women and labor-intensive care they subsequently provide to their babies has gone completely unrecognized by hospital (or the public) as the great labor-saving device it was and is. After all, it is the mother/patient herself who labors, pushes her baby out, breastfeeds and cares for it afterwards. However, hospitals ascribe this accomplishment to the brilliance of their doctors and diligence of the hard-working nursing staff, while never saying a word about the achievement of each childbearing woman without which they wouldn’t have a profitable business.

The high profit margins of lying-in wards anticipated by Dr. JWW early in the 20^th century is still true for modern maternity wards. In the late 1990s, one publication noted that for every dollar that hospitals received in direct patient fees or third-party payors (insurance companies and federal Medicaid program) their maternity departments averaged 38 cents profit (approx. 4O%), while the profit margin for cardiac care units only was only five cents on the dollar (5%). This makes maternity care 8 times more profitable for hospitals.

 

According to surveys conducted by the hospital industry, women typically make 70% of the decisions about where family members should go for medical and hospital services (ref: architectural journal). When a woman is satisfied with her childbirth experience at a particular hospital, she most often recommends that hospital to other family members, friends, neighbors and co-workers. As a result, hospital maternity departments actually make new “business” for other hospital departments and services.

This news would certainly have surprised and pleased Dr. JWW. But in 1914, he just wanted to be sure that every community with a population over 3,000 was served by at least one lying-in hospital. He saw the proliferation of lying-in hospitals would at some future time would become:

“as ubiquitous if not as numerous as schoolhouses and libraries” (verify words in this quote & get page #).

The owners and executive directors of these hospitals would one day realize that, without conscious intention, their little 2-10 bed lying-in hospital of 20 years ago had painlessly turned into a very respected general hospital that served several surrounding communities. From that standpoint, Dr. JWW’s “Plan” was a smashing success, way beyond is anyone’s wildest dreams.

So far, the one critical topic that Dr. JWW had thus far not factored in was “what if we build it and they don’t come?  What actions can we take that will guarantee a steady and profitable patronage of hospitals by maternity patients as paying customer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Field of Dreams: After we build it, how do we make them come?

This last part of Dr. JWW’s plan was equivalent to the line made famous by Kevin Costar in the popular baseball movie “Field of Dreams” which was “Build it and they will come”.

His 1914 book constantly promoted lying-in hospitals and lying-in wards while bitterly criticizing the “absurd” idea that childbirth was a normal aspect of an affluent woman’s physiology, a conversation that always led back to his promotion of lying-in hospitals.

The need of such a (lying-in) service would long ago have been evident, had it not been for the current conviction that the bearing of children is a physiological function not to be considered seriously…

 

Now that the time has arrived when a matter of such vital import can be frankly discussed in public, we may expect to see aroused a growing interest in the betterment of the condition of woman through amelioration of the evils incident to the performance of her supreme function.

Every aspect of Dr. JWW’s Plan was a perfect fit with his obstetrical colleagues  — the elective hospitalization of healthy laboring women who by merest happenstance came from families who could afford to pay a substantial hospital bill for a 14-day stay for the new mother in the hospital’s new lying-in ward and 14 days for the new baby in the hospital nursery was music to the ears of every obstetrician.

That was Dr. Williams’ hope and his goal, but when his published his Plan in 1914 it was far from a reality. Implement required:

(a) figuring out how to re-purpose or build thousands of small lying hospitals and making sure bigger hospitals already had, or added on, a lying-in ward in every population center over 3,000

(b) figuring out how to convince a million or more women every year to abandon their homes, support system of family, friends and community midwives and choose instead to be “electively” hospitalized for normal childbirth and the full 14-day lying-in period.

Over the next decades, the ideas in Dr. JWW’s Twilight Sleep book were incorporated into the obstetrical profession’s definition of childbearing as pathology-centric system that continued to act as if normal childbirth as a “nine-month disease” that required a “surgical cure” even as quit using this analogy in public. He was in complete accord with the profession’s decision to eliminate practices that treated childbirth as a biologically normal and socially-intimate affair in the family home with the support of midwives and GP doctors, and to replace it with a pathological concept that normal labor should be a heavily medicalized event and the birth a series of surgical procedures provided by a physician trained in obstetrical surgery.

But Dr. JWW was a practical man who left nothing to chance. One of many details that was important to his Plan was an aggressive public relations campaign that promoted the elective hospitalization of healthy middle- and upper-class women.

Here are his comments under the heading “Objections from Women”:

“To meet their needs [i.e. childbearing women], it would be necessary to have a small lying-in hospital located in every town of three or four thousand inhabitants. At first thought, this seems an ideal impossible of realization. But if we consider the matter with attention, without for a moment overlooking the practicalities, we shall see, I think, that such a project by no means presents insuperable difficulties.

Of course, there will be difficulties in the way of carrying out such a scheme, with its implied sojourn in a hospital for the great majority of women during their accouchement.

 

The chief objections will come from the women themselves. Indeed, this is about the only opposition that need be considered. Woman is the ruler in America, and what she wishes is never denied her. So, it remains only to gain the assent of women to put the project for the wide extension of a lying-in service ….

 

… the farm wife must be educated before she could be made to see the desirability of this arrangement. The first thought of the average wife is that she cannot possibly be spared from home and that the idea of going to the hospital is not even to be considered.

 

But as soon as the advantages offered by the hospital – painless childbirth, safety to the offspring, and rapid and permanent recovery – come to be generally known the feasibility of the project will quickly be demonstrated.

 

What a boon it will be, then, to the six million farm wives of America, when facilities have been provided, and customs have been established, making it certain that she may have the comforts of a lying-in hospital, with adequate medical attendance, to solace her in what would otherwise be the dangerous ordeal of motherhood.”

 

These comforts, it must be borne in mind, include the use of pain-annulling drugs. In this country, it is customary to anesthetize the patient with chloroform, though some competent practitioners prefer ether.

 

When soliciting active support from husbands and public official or making a pitch for capital endowments from philanthropists, Dr. JWW’s emphasized the benefits of his new system of lying-in hospitals to men and other segments of society.

 

“Incidentally, it should be noted that the male population of the community will also benefit directly from … lying-in hospitals, because it will be possible to establish in connection with these hospitals, [new] wards or departments of general surgery, for the treatment of various diseases, in many places where it would be impossible to maintain such a hospital service independently, because of insufficient patronage.  

 

The patronage of a lying-in hospital is an assured element, assuming good proportions even in districts relatively sparsely settled.”

 

And his remarks about the more abstract politics of his Plan:

“Many a man who will give for almost no other object, will make liberal donations when he is convinced that the project is one that will immeasurably decrease the dangers and practically annul the pains of the women of the community in the condition which he has hitherto contemplated with the utmost apprehension as a menace, present or prospective, to the loved ones of his household.

 

Whatever your position in the community, you can at least call the attention of your friends and neighbors to this vitally important matter.  And it may well be expected that the response will be quick. and keen; that knowledge of the movement will spread from house to house; and that the public interest aroused will lead to active steps for the establishment in your midst of an institution where the woman in childbirth may be given the solace of the “Twilight Sleep,” with all the attendant blessings that the word {i.e. solace} in its wildest implications is here meant to connote.

 

Is it not worth your while to have a share in this beneficent movement?”

 

Dr. JWW also hoped to solicit financial help from the wealthy philanthropists of his generation. Here is an ‘insider’ comment that reveals the intense professional rivalry between gynecologically-trained surgeons and obstetricians:

 

“Even were local lying-in hospitals to be established everywhere, however, there would still remain much to be done before the needs of women in connection with the great function of child-bearing have been adequately met. At present, gynecology and obstetrics are too sharply divided and are conducted upon too practical a basis to give ideal results.

 

The progressive gynecologist considers that obstetrics should include only the conduct of normal labor, or at most of such cases as can be terminated without radical operative interference, while all other conditions should be treated by him [the gynecologist] – in other words, that the obstetrician should be the man-midwife.

 

The advanced obstetrician, on the other hand, holds that everything connected with the reproductive processes of women is part of his field, and if this contention were sustained, very little would be left for the gynecologist.”

The obstetrical profession’s aggressive PR campaign in newspapers, radio and women’s magazines promoted hospital birth as the new, modern, and more “scientific” way to have a baby. Listeners were assured that women laboring in the hospital wouldn’t feel any pain and wouldn’t remember any of the ‘unpleasantries’ associated with giving birth, since they would be “mercifully” unconscious in a state of total oblivion when their babies were born.

Husbands were assured that a hospital birth, which was assumed to include the tender and around-the-clock ministrations of doctors and nurses, was a guarantee that their beloved wives and unborn babies were in the very safest of all possible places — hospital labor and delivery suite, in the hands of the very safest of all birth attendants, which they were told was doctors trained in obstetrical surgery.

It’s no surprise that childbearing women signed up to be electively hospitalized when they went into labor and their husbands lined up to express their undying gratitude for their wife’s miraculously painless delivery by prompting paying a rather substantial hospital bill for mom and the new baby.

Dr. JWW smiled in his sleep, while hospital administrators laughed all the way to the bank!

~ Obstetrical Childbirth ~
“Goose that Lays Golden Eggs” round the clock, 356 days a year

The financial high note of Dr. JWW’s innovative self-funding scheme turned out to be the goose that just kept on laying golden eggs, year after year, decade after decade, as hospitals made a handsome profit by electively hospitalizing, heavily-drugging, and “delivering” healthy childbearing women as a surgical patients that needed general anesthesia, episiotomies, a dangerously forceful form of fundal pressure, forceps extraction, manual removal of the placenta, suturing the episiotomy incision. While 80% to 90 % of these women didn’t actually “need” this highly inventive care, hospitals and doctors were happy to collect their share of the substantial fee for these unnecessary and often dangerous interventions in the normal biology of childbirth .

But Dr. JWW’s ambitions for obstetrical prominence did not end with is Plan/Scheme for elective hospitalization and lying-in hospital as the goose that lays golden eggs. He also aimed his professional ambitions at extremely wealth philanthropists – Rockefellers, Carnie, and Vanderbilts, to name but a few. Here is his well-constructed “pitch” from his book Twilight Sleep:

WHAT HALF A MILLION WOULD DO

Here, then, is a brief outline of a project for the carrying out of investigations in the interests of womankind, and for the better education of the physicians who are to minister to her physical needs.

 

And what, it will naturally be asked, stands in the way of the immediate carrying out of so beneficent a project?

 

The answer may be given in this brief sentence:  Lack of funds.

 

The initial endowment left by Johns Hopkins for the foundation of the hospital that bears his name has been kept intact.  But the entire income from it is required to conduct the various departments of the hospital on the existing basis, and it is impossible for the Trustees to apportion money, without an unjustifiable infringement on the capital, for the development of such a woman’s clinic as is absolutely prerequisite to the carrying out of such a project as Dr. Williams outlines.

 

How much money would be required?  

 

The answer seems almost ridiculous in these days of large financial enterprises.  For we are told, on competent authority, that the paltry sum of $200,000 would suffice to enlarge the present buildings devoted to the obstetrical and gynecological departments at Johns Hopkins Hospital, and that $300,000 more would suffice as an endowment for the maintenance of the additional patients.

 

Half a million dollars, then, entrusted to the wise stewardship of the Johns Hopkins authorities, would suffice to establish a woman’s clinic, in which matters that vitally concern the twenty million mothers of America would be investigated, as they are being investigated nowhere else in this country.

 

 

 

 

 

 

 

 

 

6. The Cost: Obstetrics & the Germ Theory of Disease in a Pre-Antibiotics Era

Before 1881, the entire span of the human species lived (and many millions died!) in a pre-scientific world that did not yet know that infectious disease, contagion and epidemics were all caused by microscopic organisms that were invisible to the human eye – bacteria, viruses and fungus, often lumped together and referred to simply as “germs”.

 

That all changed in an instant in 1881 when Louis Pasteur, a famous French chemist (inventor of the pasteurization process used to sterilize wine and cow’s milk) gave a presentation to the prestigious Institute of Medicine in Paris, France. In front of hundreds of Europe’s most respected medical doctors, he stepped up to a blackboard and with a piece of chalk drew a series of slightly elliptical shapes that somewhat resembled a chain of tanker cars sitting on a railroad track. Then he turned back to the assembly and said:

“This, gentlemen, is the cause of puerperal sepsis (the deadly infection also known as “childbed fever”).

 

Then Pasteur went on to explain that his drawing was a representation of the bacteria Streptococcus pyogenes, the deadly bacteria responsible for “hospital fever” in post-op patients and “childbed fever” in newly delivered mothers. Streptococci is just one of many a human-specific bacterial pathogen that causes infections of various degrees of virility including sepsis, now referred to as ‘septicemia’ but often described as “blood poisoning”.

 

Before the discovery (1928) and availability of antibiotics (1945), virulent strains of this and other bacteria caused multiple organ failure for which there was no treatment and inevitably resulted in the patient’s death. While Teddy Roosevelt was president, his teenage son hurt one of his toes while playing tennis, and despite the best medical attention by doctors in Washington D. C., he developed septicemia. All the King’s horses and all the King’s medical men could not keep the President’s son from dying.

 

The ascendancy of American obstetrics occurred during an awkward in-between stage that was after the discovery of microscopic pathogens (pathological bacteria, etc.) but before the discovery of sulfa, penicillin and other antibiotics.

 

In this pre-antibiotic era, the obstetrical profession had already declared, with great public fanfare, that the new American standard of care for normal childbirth consisted of a host of what actually were unnecessary and unscientific interventions and invasive treatments. In the many decades before sulfa drugs became available (1937) and antibiotics (penicillin, 1945), policies practices that promoted the routine use obstetrical interventive and multiple surgical procedures were extraordinarily risky and dramatically increased maternal and infant mortality.

 

Of the 10 top potentially-fatal complications associated with childbearing, such as pregnancy-related toxemia and postpartum hemorrhage, just one – puerperal sepsis or septicemia – accounted for 40% of all maternal deaths before availability of antibiotics. The second most frequent cause of maternal death was postpartum hemorrhage, a complication that is greatly increased in women given general anesthesia.

Nonetheless, what apparently did NOT figure into these obstetrical policies in a pre-antibiotic era was the general risks of infection associated with the hospitalization of all types of patients, combined with the extraordinary risks that accompanied the routine use of invasive obstetrical procedures – frequent vaginal exams, episiotomy incision, use of forceps, reaching up thru the newly-delivered mother’s vagina and into her uterus to remove the placenta. Inexplicably, the obstetrical profession decreed that its interventive labor and birth practices applied to all childbirth services for all childbearing women, not just those who had high-risk pregnancies or complications, but healthy women with perfectly normal term pregnancies as well.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Lowest Ring of Hell: 1900 to the 1990s ~ Flipside of Dr JWW’s Plan included injecting pregnant women with Twilight Sleep drugs and strapping them to their hospital beds

For the healthy, economically-advantaged childbearing women being electively admitted to a hospital’s labor and delivery ward, this was perhaps the deepest and darkest pit of their entire lives, the lowest rung on a ladder to hell, one they didn’t understand and most certainly did NOT consent to in any truly informed or legally valid way!

Decade after decades, generation after generation, childbearing women were systematically forced to endure the unendurable. If they were lucky, they were unconscious and the inevitable abuse they endured was unremembered, at least by their conscious mind, although it may have left permanent a mark as post-traumatic stress syndrome during a time when such issues were not understood or acknowledged by the medical profession.

But if these new mothers-to-be were among the unlucky ones, they were left with life-long brain damage from an anesthetic accident of some sort, physical disabilities resulting from the use of obstetrical forceps or, worse-case scenario, a totally preventable premature death.

 

This was a profoundly dysfunctional system from any perspective. In the very early 1900s, annual maternal mortality rate in the US ranged from 520 to 850 per 100,000, while the rate for England and Wales was 440 per 100,000 and the MMR in Sweden was only 230 per 100,000 live births or one third that in the United States. This caused some in Western countries to believe it was associated mainly with the emergence of modern obstetric care.

 

In 1925, 25,000 childbearing women died in the US under the obstetrical profession’s interventionist policies – a mortality rate that was orders-of-magnitude greater than women living in dozens of other industrialized countries.  At a time when the very highest MMR in other developed countries was 400 per 100,000 birth (i.e. ratio of 1: 250 births), the US had a staggering 1,225 maternal death rate per 100K, or ratio of 1 mother dying out of every 80 births.

 

There is no excuse for what I can only think of as something a kin to “organized crime” in the guise of making childbirth safer by getting rid of those old-fashion midwives and putting laboring women in the hospital where they belonged! This was madness, plain and simple.

 

A paper published in the American Journal of Public Health included comparative statistics on the maternal mortality in various developed countries in the early 1900s and noted the rate of maternal deaths in the US was higher than any other industrialized country. Here is a brief excerpt:

 

“This very high maternal mortality rate, especially if compared with the lower rates achieved in several less prosperous European countries, caused some American obstetricians to express concern.

 

Joseph B. DeLee, … a titan of 20th-century obstetrics, studied maternity services in Europe before he established the Chicago Lying-In Hospital and Dispensary in 1895. His aim was to provide delivery assistance to poor women by also offering them the option of having a safe and inexpensive home delivery.[4]

 

{Obstetrician} George W. Kosmak visited Scandinavia in 1926 and was reported to have been very impressed with the medical systems in place there. In an address to the American Medical Association, Kosmak talked about the good results obtained in a carefully supervised system of midwife instruction and practice. He stated,

 

“To begin with, the midwife in Scandinavia is not regarded as a pariah. . . . One sees, therefore, in the training schools for midwives, bright, healthy looking, intelligent young women of the type from whom our best class of trained nurses would be recruited in this country, who are proud of being associated with an important community work, and whose profession is recognized by medical men as an important factor in the art of obstetrics, with which they have no quarrel.”

 

He concluded, “The results of this midwife training are evidently excellent because the mortality rates of these countries are remarkably low and likewise, the morbidity following childbirth.” [5]

 

The Decline of Maternal Mortality in Sweden: The Role of Community Midwifery;
American Journal of Public Health | August 2004, Vol 94, No. 8

In 1932 Testimony on the efficacy of midwifery care was presented to the White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care: Reed (1932) concluded:

“…that untrained midwives approach, and trained midwives surpass, the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child.

On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.” (italicized emphasis in original publication) <White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care, pub. 1932>

Shortly after the 1932 the White House report on the greater safety of physiologically-based care associated with the care of professionally trained midwives became public, a report with similar finding was published by Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after he analyzing the work of the Frontier Nurses’ midwifery service in rural Kentucky.

Dr. Louis Dublin made the following public statement on May 9, 1932:

“The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life.” < Met Life; 1932>

No less a person than an 3^rd vice president and MD-statistician for a life insurance company reported that the professional training midwives and universal access to midwifery care would save 70,000 lives of mothers and babies a year. But we already know that the response by the obstetrical professional was their usual blind eye, deaf ear and stonewalling on steroids!

The information provided in the White House report and by Dr. Dublin is in stark (and depressing!) contrast to 1975 article published in the New York Times Magazine the (erroneously) characterizes physicians as saving mothers from the “dangers” of midwifery care by forcing midwives out to the “childbirth business”. Today it is rare for a woman to die in childbirth and infant mortality is (low).

“In the United States … in the early part of this century, the medical establishment forced midwives — who were then largely old-fashioned untrained “grannies” — out of the childbirth business. Maternal and infant mortality was appallingly high in those days…

~ “As the developing specialty of obstetrics attacked the problem, women were persuaded to have their babies in hospitals, and to be delivered by physicians…. Today it is rare for a woman to die in childbirth and infant mortality is (low)…” [NYTM; Steinmann, 1975]

Notice the editorial trick in which two factually true statements that have nothing directly to do with each other are paired together in two different places as a “cause-and-effect” combination that is false both times.

First is the comment about forcing midwives “out of the childbirth business”, followed by the phase “appallingly high maternal mortality rate”. This fact was reported by Dr. Zeigler in 1922 as a direct result of appallingly poor medical education and poor obstetrical practices and having nothing to do with midwives. This inappropriate pairing both dismissed and maligned the reputation of midwives, while misrepresenting the actual origin of the earlier high maternal-infant rate, which was poor training of doctors and faulty obstetrical practices.

This is followed another pair of disingenuous statement. The first one describes how the “developing specialty of obstetrics attacked the problem” and persuaded women to have their babies delivered by a doctor in a hospital. Then the last of those paired sentences says: “Today it is rare for a woman to die in childbirth and infant mortality is (low)”. Apparently, the logical conclusion is that replacing midwives with doctors and obstetrical interventions is what finally made childbirth safe for American women.

these objective statistics made no difference as the campaign against midwifery by the obstetrical profession went on unabated decade after decade after decade.

Unfortunately, this disparity between the MMR in America and that of comparable developed countries is not that different today, as US ranks in 127^th in maternal mortality out of a total of 182 countries. A healthy childbearing woman is safer in 126 other countries, a list that includes unlikely and hard-to-pronounce place names such as Slovenia, Turkmenistan, Macedonia, Malta, Montenegro, Slovakia, Lithuania, the Czech Republic, Poland, and Belarus.

 

“The more things change, the more they stay the same” apparently applies to obstetrics in America!

Middle- and Upper-class women as unwitting participants in Dr. JWW’s “scheme”

But all these economically-secure laboring women had one thing in common – they were all an unwitting part of a scheme whose hidden agenda was to provide paying customers for new lying-in wards – by the electively hospitalizing economically-advantaged women.

From the hospital’s perspective, more lying-in patients as paying customers meant more profit, which would eventually become a general hospital serving surrounding communities as part of a nationwide system like the ones in Europe. But there was one stunning difference btw general hospitals in the US as compared to European countries. In European countries, all working adults paid taxes and their governments used this tax revenue to build, staff, equip, educate, and maintain a regional system of general hospitals that in turn provided healthcare to the entire populations. The costs and the rewards were spread across the entire population. There is a symmetry in that scenario that is almost poetic – all who are able pay in, all who are in need receive.

But in the US, the AMA’s perpetual temper tantrum against “socialized medicine” and it’s “biggest bully on the block” political persona, in which it metaphorically threatened elected officials with the clear message of “you’ll be sorry if you don’t go along with us” meant that public funding was DOA. Given the size, scope, financial resources and sustained efforts by organized medicine, there is little wonder they got what they wanted 99.99% of the time.

Instead of the US government underwriting a badly needed national system of general hospitals funded by the combine wealth of our population (taxes paid by working adults), Dr. William figured out how to secretly tap into the wealth of middle and upper-class childbearing families and extract what it needed to provide a so-called “self-financing” Plan.

 

This began with the creation of lying-in hospitals and wards in the thousands of small and medium-sized private hospitals that already dotted the countryside. With a steady infusion of cash from their new lying-in wards and the time necessary to accomplish their goal, many of these ill-equipped hospitals would undergo a ‘make-over’ and slowly morph into the longed-for nationwide system of comprehensive general hospitals.

 

However, it is a misuse, or at least misleading use, of the concept of  “self-funding” or “self-financing” when the money they were using did not come from investors or a bank loan that would ultimately need to be repaid out of the profits generated by the legitimate medical business of hospitals – services provide to people who needed them.

 

What Dr. JWW’s Plan did instead was extracted money under false pretenses from the families of these health childbearing women based on a story made-up by him (a lie) that affluent white women suffered from a weird “vitamin deficiency” of some sort, in that they were not getting enough narcotics and hallucinogenic drugs during labor, and not enough chloroform and ether during the birth, not enough episiotomies, not enough forceps deliveries, not enough manual removals of their placentas and not enough stitches after giving birth.

 

Dr. JWW’s Plan enticed well-off families to “shop” at our “hospital” for your childbirth needs, not because the drugs and surgical interventions we are selling are intrinsically better than the normal biological process of a spontaneous childbirth, but because thousands of America’s small hospitals need your money so they can upgrade, remodel, expand and someday grow into a community-based general hospital without waking up the AMA’s “anti-socialized medicine” avatar all dressed up in its evil witch costume .

All those doctors who owned lying-in hospitals or lying-in wards were proud and happy to brag about this financial slight-of-hand done without a single penny of public tax money, to the delight and encouragement of the AMA. Every hospital with a lying-in ward had figured out how to turn the normal biology of childbirth in a pot of gold at the end its own private rainbow. Leaders of the AMA smiled into their hands about how smart they were to have pulled this rather tricky rabbit out their hat.

The AMA successful policy was “just say no”, stick to your guns, don’t ever cooperate or show a scintilla of remorse, no matter how abusive the system is or many mothers and babies die, after all we won, we got our way again – read my lips, we didn’t need any new taxes because lying-in hospitals and lying-in wards figured out how to turn hospital-based normal childbirth for healthy women into a cash cow.

Maternity wards are still a disproportionate source of revenue for American hospitals. As mentioned earlier, a financial report published in the 1990s reported that almost 40 cents of every dollar hospital received came from its maternity department, compared with a profit margin of just 5 cents for services provide by the hospital’s cardiac unit.

Equally fortuitous was the uncritical acceptance by electively hospitalized maternity patients and families that never even suspected they were being hood-winked – sold a magical but dangerous story that had real “life and death” consequences.

God bless scopolamine and general anesthesia! After all, you can hide a lot of dirty laundry under the noses of women rendered “oblivious” by amnesic drugs and anesthesia as described by Dr. JWW.

Mandatory ‘Vows of Silence’ ~ law-of-the-land for hospital L&D staff

Hiding the abusive nature of hospital labor wards was helped along by the big black letters on the swinging doors to the L&D ward that read: ”NO ADMITTANCE – Authorized Personnel Only”. No family members who was concerned for the safety of their beloved wife or daughter was ever allowed to see what went on behind those infamous swinging doors – the abusive practices that were a routine part of elective hospitalization. Of course, no one, not even family members, would believe what a childbearing woman said about her experience in that House of Horrors while under the influence narcotics and hallucinogenic drugs.

The public was likewise screened off from the secret society of doctors and nurses who worked in hospital L&D units, and performed “baby-ectomies” every hour of every day as unborn babies were wrestled out of their mother’s unconscious body with obstetrical forceps – all in the name of safer, better, more humane care and the mirage of totally “painless childbirth”. Only the hospital staff — the very L&D employees who administered these drugs and associated abusive practices — and who routinely carried out all those medically unnecessary operative deliveries were ever allowed to see what happened behind the closed doors of the labor ward.

Yep, if you knock the mother out cold, she’ll never ever know what hit her, and just as “dead men tell no tales”, heavily drugged and unconscious labor patients are equally unable to point to those who committed crimes upon their bodies.

The stiff-armed policies of hospital labor wards remained a professional secret generation after generation after generation. Whenever their policies were challenged, an official hospital spokesman insisted that restricted access to the L&D ward was necessary to maintain the surgical unit’s sterility and prevent infections, allow nurses to do their jobs without distraction of visitors and to protect the privacy of laboring women from the gazes of men who were not their husbands.

It wasn’t until 1953 that a few brave L&D nurses blew the whistle on the “cruel and unusual” practices that were iron-clad hospital policy in virtually every labor ward all across American from 1910 to 1960 and in many small rural hospitals, until the 1990s. For the first time ever, these “tell all” letters were published in a popular women’s magazine and triggered a flood of letters from mothers who’d labored and given birth under these horrific conditions, with each woman recounting the substantial and/or sustained brutality she’d been subjected to while in labor or giving birth.

But even hundreds of letters published in a popular magazine with national circulations were enough to abolish these practices, or even trigger a panel to “investigate” the systematic and institutionalized abuse of all laboring women in American hospital wards, so “the beat went on”, as obstetrics continued to insulate itself from any of the realities of the childbearing “patients” served but as a profession did ot respect.

Fetus as the obstetrical profession’s Primary Patient – Williams Obstetrics, 1974

Another historical incident indictive of the obstetrical profession’s having no guard rails and going completely off the reservation (i.e. professional understanding or sympathy for childbearing women) and gotten itself lost in the high weeds came about with the 1974 publication of the 20th edition of Williams’ Obstetrics, a 1,547-page obstetrical textbook.

The book’s foreword enthusiastically welcomes the budding new technologies of obstetrical ultrasound and electronic fetal monitoring as finally providing the obstetrical profession with the tools they need to make the fetus the obstetrician’s primary patient.

According to the textbook’s many authors, the obstetrical profession had been long seeking this goal, and obstetricians were so obviously pleased to announce that it had finally, through the miracle of modern medical technology, the fetus as primary patient had become a reality!

However, as a brief historical aside, I must report that the authors apparently did not have the last word on the information presented in this edition of Williams Obstetrics. In the index of the 20th edition, under the letter C, is an entry that reads:

“Chauvinism, pages 1- through 1,547”.

No doubt an unauthorized addition made by an anonymous print shop employee, who undoubtedly was a childbearing woman who’d personally “been there and done that” and knew misogyny when she saw it!

 

 

 

8. An Undeclared Medical Experient ~ Normalizing Childbirth as Surgical Procedure Note to self  maybe move to part two?

 

Dr. Williams publicly claimed that economically secure white pregnant women were not getting enough narcotics and hallucinogenic drugs during labor, and not enough chloroform and ether during the birth, not enough episiotomies, not enough forceps deliveries, not enough manual removals of their placentas and not enough stitches after giving birth vaginally.

 

But as note earlier, Dr. JWW’s claims were not based on scientific evidence, but on a big, black lie invented by him to serve his two-part Plan. The central falsehood was companied by a bevy of less egregious lies and half-truths. Together, the false pretenses and lies of omission wove a dark and deeply menacing story that goes against our common sense, direct experience, and all the scientific facts of the 21^st century. In plain English:

 

To replace the biology of normal childbirth in the affluent classes of while women with a series of obstetrical interventions, both medical and surgical, to be systematically employed during labor and normal childbirth as the new American standard of care for healthy childbearing women.

 

All this was unscientifically unproven, and dangerous in the early 20^th century, and the current style of obstetrical interventions – particularly the routine use of continuous electronic fetal monitoring (EFM), prophylactic inductions of labor in healthy women with normal pregnancies and increased danger associated with the “liberal” and elective use of Cesarean surgery continues to be scientifically unsound and not evidence-based here in the 21^st century.

The profession’s decision in the early 1900s turn normal childbirth in healthy women into a series of surgical procedures was (and remains) a medical experiment that lacks any scientific evidence of safety or efficacy. Without the support of scientifically-valid conclusions, the obstetrical profession decreed that childbirth was to be defined as a surgical process attended by physicians with training in obstetrical surgery.

This medical experiment was conducted without the obstetrical profession publicly acknowledging the unproven and experimental nature of policies and practices they had long been promoting as cutting edge in safety for American women. As a medical experiment, normal labor was turned into a hospital-based process that included repeated doses of narcotics and mind-altering drugs and the birth conducted as a surgical operation that included the frequently-repeated list of six major and independently dangerous surgical procedures – anesthesia, episiotomy, forceful fundal pressure, forceps, placental extraction, suturing the perineal incision.

During the pre-antibiotic era (prior to 1945) childbearing women were also not informed about the danger of lethal infection associated with hospitalization, which exposed these healthy women to the deadly bacterial diseases that lurked in every nook and cranny of hospitals. Bacteria in general and highly resistant strains that populated hospitals in particular were responsible for the virulent infections that accounted for 40% of maternal deaths. Instead obstetrical patients were told that if they would agree to elective hospitalization, they could trust their doctors and hospital L&D nurses to provide the very best modern, scientific, and state-of-the-art care. Simply put, this was a lie.

Perspective obstetrical patients were never provided with any of the information about their treatment that would now be legally required for a patient to provide “informed consent”. None of these routine interventions, either independently or as a unified protocol, had at the time, or in the hundred years since, ever been scientifically established to be (a) necessary, (b) beneficial or (c) safe to during the intrapartum care of healthy women with normal pregnancies.

One particularly egregious aspect of the way the virtually all-male obstetrical profession treated it women patients was the suturing of the new mother’s episiotomy incision while she was still unconscious and that is the infamous “husband stitch”. Doctors regularly sewed the new mother’s vagina up “extra tight” so husbands will not come back later and complain to the doctor that:

“ever since my wife had the baby, having sex with her is like walking into a warm room.”

In the intervening 100 years, these policies and routine practice have been amply and repeatedly proven to be dangerous and have no redeeming value, either medically, socially or economically, when used as a protocol for obstetrical services provided to healthy women with normal pregnancies.

Instead they are:

• harmful
• unnecessary
• unproductively expensive
• dangerous when used on healthy women with normal pregnancies

Any contemporary obstetrician who employed these same protocols today would be stripped of his hospital practice privileges, the state medical board would revoke his/her license, and if s/he were sued, would be found guilty of egregious medical malpractice.

Two rationales used to explain and maintain the wrong and dangerous use of obstetrics

Obstetrics is apparently the “Teflon” profession, as it continues to enjoy a special protection and freedom from accountability for the harm it does and the unproductive expensive it generates. Fifty percent of all births in America are billed to the federal Medicaid program and the rate of C-sections performed is higher for women who qualify for Medicaid than those who have private insurance, so this loosey-goosey system of very-low-to-no accountability for surgical interventions by obstetricians is easy and profitable.

The excerpt below is from Dr. Guttmacher 1937 book “Into this Universe”, and describes the obvious dangers of using obstetrical interventions and invasive procedures such as forceps. He identifies a direct correlation between a country’s high rate of maternal mortality, compared to similar developed countries that rarely intervene in  on physiologica management typically by midwife  between developed countries that  in US that are associated with  and noting the contrasting orders-of-magnitude lower MMR in Sweden, Netherlands, other countries where they do not “depend on instruments and “brawn” to drag the baby out has

“Though we cannot make an exact comparison between the maternal mortality in the United States and that in European countries, we can at least make a rough comparison. All who have studied the problem agree that the rate for Holland, Norway, Sweden, Denmark is far superior to our own.

 

Why?  … it must be due to a difference in the patients themselves and differences in the way that pregnancy and labor are conducted in the two regions.” [1937-A Into the Universe by Dr Guttmacher, MD] p. 133-134

 

“What about the conduct of labor in the two regions? Here is where the major differences lie. In the first place, … at least 10 percent of labors in this country are terminated by operation. In the New York Report 20 percent of the deliveries were operative, with a death rate of more that 1 in each 100 of the operated, and 1 in 500 of those who delivered spontaneously. ” [1937-A Into the Universe; Dr Guttmacher, 1937]

 

“Let us compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. In Sweden the [operative] interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland ….. it is under 1 percent.” [1937-A]

 

“What is responsible for this vast difference in operative rates? … Analgesics [narcotic drugs] and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted.

 

And midwives are trained to look upon birth as a natural function, which rarely requires artificial aid from steel or brawn. [1937-A]

 

The obstetrical profession obviously ignored or denied that the dramatical change it proposed in the early 1900s was radial, dangerous and indefensible. Instead it developed two rationales to be used by politically-influential obstetricians to justify this undeclared medical experiment.

The first was the “humanitarian” pitch that the act of categorizing childbearing women as surgical patients was simply a modern upgrade. As surgical patients, they would be provided with all the ‘advantages’ of “pain-annulling drugs” and “anesthetizing the patient with chloroform”. However, this rational left out the well-known fact that the invasive nature of hospital obstetrical care included more than a half a dozen surgical procedures.

Each one of these dramatically increased the likelihood of developing a life-threatening infection and the biological stress having several of these bodily assaults all at one time could easily overwhelm the body immune system and result in a massive infection. (Dr. DeLee’s 1924 textbook Principles and Practice of Obstetrics; look up page#),

Before the discovery of antibiotics, one of the major dangers posed by the indiscriminate use of obstetrical interventions was fatal infection. This kind of body-wide infection is often referred to by the lay public as “blood poisoning”. Its official name is “septicemia”, which is a life-threatening condition in which the bacterial load is so great in both in amount and virility that is causes body organs – kidneys, liver, lungs, heart, brain — to fail one by one until death intervenes.

If you study the statistics and other records for maternal mortality in American obstetrics you see the rate of maternal deaths climbed steadily upward in conjunction with the steadily increasing rate of hospital births from the early 1900s until the late 1930s. Then in the late 1930s and very early 1940s, the MMR begins to fall precipitously as a result of antibacterial sulfa drug, which was able to successfully treat many ‘hospital’ and ‘childbirth’ fevers. An even more dramatic drop in the MMR can be seen when the antibiotic penicillin became available in 1945.

After the availability of antibiotics, women exposed to these very same obstetrical interventions who developed “childbed fever” did not die because they could be treated with antibiotics. In essence, antibiotics made the indiscriminate use of obstetrical interventions “safer”, not because the interventions themselves were any safer or more useful, but simply because the harm they caused could be ameliorated with the administration of more drugs – in this case, the ‘wonder drug’ of antibiotics.

As citizens, we need to be especially skeptical when the use drugs and other medical and surgical methods become necessary to reverse or reduce the harm caused by the use of drugs and other medical and surgical methods.

The second justification for elective hospitalization of healthy maternity patients focused on the immutable fact that women who are expected to have a normal birth occasionally develop an unexpected complication requiring obstetrical intervention. In those case, obstetricians stressed the great advantage of having all “obstetrical patients” pre-emptively hospitalized even though only a small fraction of healthy women needed obstetrical interventions.

This not a medically valid reason for pre-emptive hospitalization, administration of drugs and anesthesia, performing forceps deliveries and placental extractions as the standard of care for 100% of the childbearing populations and doing so without patient consent. This treatment regime dramatically increases the risk of serious complications and maternal deaths, especially from anesthetics accidents (at the time the 3^rd leading cause of maternal mortality) and postpartum hemorrhage due to placental extraction.

What if a group of surgeons decided they would pre-emptively prevent breast cancers by routinely performing radical mastectomies on all adult women? This might would prevent the majority of breast cancers, but millions of unnecessary major surgeries each year would result in a great many iatrogenic complications and deaths in these patients, not to mention the physical and psychological harm to women themselves, burden on the healthcare system and economic expense to society.

~© Obstetrical Profession stops a successful hospital-based Nurse-midwifery program providinh physiological management of normal birth to low-income women

The undeclared medical experiment in normalizing childbirth as surgical procedure is not the only instance of the obstetrical profession working against evidence-based scientific principles. In 1963, lobbyists for the American College of Obstetrics and Gynecologists {ACOG) actually stopped a nurse-midwifery program that provided physiological management of normal childbirth in the hospital.

From July 1960 to June 1963, a pilot nurse-midwife program established at Madera County Hospital in California that served mainly poor agricultural workers. During the three-year program, prenatal care increased, and prematurity and neonatal mortality rate decreased at the county hospital.

After it was discontinued by the California Medical Association, the neonatal mortality rate increased even among those women who had received no prenatal care. This suggests that the intrapartum care by nurse-midwifes may have been far more skillful than delivery by physicians. Prenatal care decreased while prematurity rose from 6.6 to 9.8% and neonatal mortality rose from 10.3 to 32.1 per 1,000 live births. The study concluded that the discontinuation of the nurse-midwives’ services was the major factor in these changes. [Levy, et al, 1971].

9. Private vs Public Financing for Dr. JWW’s Plan (some redundancy, some new)   

Europe’s regional general hospitals had the poetic symmetry in which the “the People’s” money — hard-working citizens who were generally proud to pay their taxes – was returned as the extraordinary humanitarian service that timely and affordable access to a general hospital is to every community.

So how did we handle this same problem on our side of “the pond”?

Beginning with Dr. JWW’s fanciful but convenient prevarication about “pathological labor pains” for “civilized”, “sensitive” and “intellectual” women, the American obstetrical system tricked, enmasse, an entire demographic – America’s better-off families — into having a hospital birth primarily so hospitals could collect the fee for a service that:

• was not medically needed or appropriate
• was drastically misrepresented
• did NOT meet the biological, psychological and social needs of healthy childbearing women
• was so incredibly harmful as to represent systematic malpractice and in some cases, criminal assault and battery and in tragically, others to include double manslaughter as mother and baby both died a totally preventable death.

How could the entire obstetrical system, which attended births in hospitals all across the country, get away with these dangerous and humiliating childbirth practices? Why didn’t these electively hospitalized women (or their nurses) say something, why didn’t they blow the whistle?

Easy answer – the “system” systematically drugged these middle and upper-class wives so no one would know that we, the American public, was being duped and this same ‘system’ fired nurses that questioned these practices or spoke out in public.  I know, as I was one of those fired for these reasons.

Disorganized Crime ~ An “Thought Experiment”

Consider the following imaginary scenario in light of its very real modern-day legal implication. What if another medical discipline formed a professional organization for a group of kidney specialists that owned dialysis clinics.

What do you suppose local DAs would do if tipped off that doctors at all these clinics regularly misinformed people with perfectly healthy kidneys, and under false pretenses, got them to agree to twice-weekly appointments for kidney dialysis? This was not because these ‘patients’ needed kidney dialysis, just that selling the service, whether or not the patient needed it, was very profitable. These MD-owners weren’t bad people, but they wanted to buy a franchised chain of dialysis clinics, some of which were in low-income neighborhood and served Medicaid-eligible patients and so they convinced themselves this was a perfectly justifiable business plan. Nonetheless, this would be considered a crime in every state.

Hard Questions with No Easy Answers     

Why did the American medical profession allow Dr. Williams, who was followed by successive generations of obstetricians, to get away with such a blatant financial scheme? Because the creation of new lying-in hospitals and wards became a self-funding system that completely eliminated the contentious politics of government funding, which made the AMA happily complicit. Everyone who was anyone in the medical hierarchy decided not to ask embarrassing questions like:

“How come this pathological labor pain syndrome that you claim is an ‘evolutionary fluke’ only affects the upper classes of white women?”

Can’t help but think that one answer is that these women were American born and wealthy, which is to say, they were NOT poor, or brown, or black or a member of any other maligned ethic minority.

Why did we The People ‘let’ it happen? Why didn’t some of these doctors and L&D nurse get together say to Dr. JWW or to the AMA: “Sorry Charlie, we aren’t folding on this one, it’s too important, and your ‘scheme’ – financing our general hospitals by picking the pockets of middle and upper-class childbearing families–  is not just un-American, but unprofessional and shamefully corrupt!”

In Dr. JWW’s scheme, husbands and other family members paid “good” money for these hospital-based maternity services for successive generations of mothers-to-be who were thrown into the hell that was “Twilight-Sleep”. They and their families thought they were paying for the privilege of superior care – substantially safer, better, more humane for both mother and baby than the ‘old-fashioned’ support for normal biology. No indeed, husbands really believe that their wives would get much better care by being electively hospitalized. However, what happened to their beloved wife was neither better or safer and in too many instances ended in tragedy

After kissing their wives good-by at the labor room door, these well-motivated husbands went home to wait by the phone, anxious to find out if the new baby was a girl or a boy and if their wife alright. Sadly, an astonishingly large number of them would be told that the baby was born but despite the doctor’s best effort, it died, or the baby was fine but their wife “didn’t make it”, or in some cases, that both mother and baby had been lost.

As part of modern medical research, scientists cage rats so “important” medical experiments can be conducted. The idea is repugnant, but we accept it as a necessary part of the “greater good” for society. New scientific knowledge advances the abilities of medical science to the mutual good of all “humanity”.  Unfortunately, the same cannot be said for Dr. JWW’s the economic experiment in ‘self-funding’ as a euphemism for having middle and upper-class family fooled into thinking that elective hospitalization for normal birth was being recommend out of great concern for their comfort and welfare but they got drugged and exposed to unnecessary medical inference and dangerous surgical practices!

Instead of being attended during labor by close family members, dear friends and supported by a midwife or doctor the laboring women already knew, the hospitalized labor patient got put out of her mine with frequently repeated injections of Twilight Sleep drugs. Doctors told families that Twilight Sleep drugs made labor “painless”, but that is not how the drug scopolamine works. The laboring women feels the same pain with every contraction that she otherwise would. Just a few pennies of her hospital bill paid for the drugs and anesthetics that L&D units use to keeps women from remembering what was done to them while they were in labor and when giving birth.

Much to the relief of the nursing staff, these drugs keep the laboring woman from remembering that the L&D nurses bound their arms and legs in leather restraints buckled to the four corners of their bed,  forcing them to lay flat on their backs and labor in the very most uncomfortable position. This seriously impedes the flow of oxygenated blood to the placenta, which means that poorly-oxygenated blood is being circulated via the umbilical cord to their unborn babies. This dramatically increases the odds that their baby would be one of those that just didn’t breathe after being born.

Perhaps not remembering this abuse and associated tragedies might be worth the entire cost of their 14-day stay in the hospital.

But it would make so much more sense, is statistically well established as so much safe  for these healthy women  to just stay home when they went into in labor, in a place where the laboring woman is safe from the dangers of narcotics, mind-altering amnesic and hallucinogenic and other dangerous drugs and that whole litany of unnecessary and unwanted surgical procedures, most especially the anesthesia, forceful and dangerous fundal pressure, forceps delivery and manual extraction of the placenta that risk introducing potentially lethal bacteria and as a trigger for a potential fatal postpartum hemorrhage and a narcotized baby so respiratorily-depressed that it can’t breathe on its own after being born.

The money the family would otherwise have paid to the hospital for those big doses of morphine, scopolamine and chloroform, the ‘generous’ episiotomy, dangerous fundal pressure on the mothers contracted uterus while the doctor “performs” a  baby-ectomy with forceps, and the not-to-be missed experience of having one placenta manual removed  – that money can just stay in the family’s pocket or be used to pay a professional birth attendant to support the biological process and just have a normal birth without surgical scalpels, forceps and anyone sticking their hand up into your uterus.

 

 

 

 

 

 

 

10. Replacing Vaginal Birth with Routine Cesarean Surgery ~
    Unforgivable Insult to Logic, Reason & Childbearing Women

In 1985, a peer-reviewed paper was published in the prestigious New England Journal of Medicine by obstetricians George B. Friedman and Jennie A. Feldman ~ NEJM; May 1985, entitled: “Prophylactic Cesarean Section at Term?”

Its authors made a strong case for the routine use of “prophylactic” Cesarean at term as a way for the obstetrical profession to permanently eliminate the danger that vaginal birth can at times pose to the unborn and newborn baby.

The authors claimed this method for providing safer births to babies would entail only a small increase in the number of “excess” maternal deaths and “extra maternal mortality”. (p. 1266)

“….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000… [emphasis added]

… if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of healthy infants at a relatively low cost of excess maternal mortality.” [emphasis added]

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 ….

Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure? [emphasis added]

….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached? [emphasis added]

If a patient considers the procedure (i.e. routine CS @ term) and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery?” p. 1267 [emphasis added]

The statement that strikes me as most absurd is the “probably” in this sentence:

“We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10…? ”.

If you really care about babies, the first and most important things you can do for the baby is to ensure the life and well-being of its birth mother. If society concludes that the mother’s life is “expendable”, I must ask: who will love, feed, care for, educate and raise the baby? In the real world, one in which single, divorced or widowed women frequently have babies, their orphaned children would be massively handicapped and become a financial burden to society.

Even if the birth father is able to both work and care for an infant, the death of one’s wife and mother of one child is both tragic and traumatizing. While the author describe their intentions as ‘protecting’ the lives of newborn babies, I suggest they think bigger than the baby’s 5-minute Agar and desire of obstetrical providers to avoid malpractice suits at all costs. These authors need to relate to newborn babies as having a long life beyond their hospital discharge sheet that lists them as a ‘healthy newborn’, because the very the best start in life for a baby is having one’s mother be alive and healthy.

New England Journal of Medicine – what were you thinking? or were you drinking?

But the bigger issue in this NEJM paper is far more than the stunningly stupid and offensive ideas of these two authors – that sacrificing childbearing women via “excess maternal mortality” as a way to contribute to the well-being of babies. After all, these are just the opinions of two people and not public ‘policy’. But unless they meant as a Halloween joke by the NEJM, publishing such unspeakably vile opinions in the most prestigious peer-review medical journals in the United States is another matter.

Being a ‘peer-reviewed’ journal means these ideas were approved for publication by a significant number of other obstetricians, as well editors and other member of the NEJM professional staff. Approval and publications of a professional paper in the NEJM signifies that the ideas in it have been “vetted” as ethical, scientifically sound, functionally credible, to be considered seriously — in this case, that perhaps a system for generating ‘excess maternal mortality’ should become the standard of care in American hospitals. Really?

And perhaps even most inexplicable, there was no outcry by the hundreds of thousands of doctors who subscribe to the NEJM, university libraries all across American that subscribe to the NEJM, the public, the press or the broadcast media — zip, zero, zilch!

It seems to me that the warped ideas in this 1984 paper were only possible in the artificial world created by Dr. JWW’s 1914 business plan. His reason for electively hospitalizing affluent maternity patients had absolutely nothing to do with honestly serving the actual needs of healthy, wealthy childbearing women. Instead it all hinged on a lie – the actual purpose was to use income from thousands of medically-unnecessary hospitalizations to generate a dependable and profitable revenue stream year after year — an ATM that conveniently provided unlimited amounts of cash for turning small and medium-sized hospitals into general hospitals.

The logical, ethical and appropriate source of financing for general hospitals should have been the federal government. Dr. JWW’s unethical “work around” only became necessary because the American Medical Association was far more interested and committed to protecting the business opportunities of medical providers than safely and honestly meeting the actual medical needs of Americans.

While funding a general hospital system was a good thing for America, lying as the basic business model for hospitals was bad then and its bad now. Unfortunately, unethical thinking and slip-sliding around the truth got ‘baked into the cake’ of modern obstetrical care and poisoned the well for generations to come. The AMA needs to revisit its obstructionist policies and it’s not too late to replace Dr. JWW’s big lie with the simple truth – obstetrics is not meant for healthy childbearing women.

Maternity care can and should work for everyone — mother, midwives, family practice physicians, obstetricians, hospitals, and the people who pay the bills should get what they are paying for!

 

@@@@@@@@@@@@@@@@ Temporary Parking / Barking lot @@@@@@@@@@@@@@@@@@@@@@@@

Fetus as the obstetrical profession’s Primary Patient – Williams Obstetrics, 1974

The 20th edition of Williams’ Obstetrics is a 1,547-page textbook published 1974. The book’s foreword enthusiastically welcomes the new technologies of obstetrical ultrasound and electronic fetal monitoring as finally providing the obstetrical profession with the tools they need to make the fetus the obstetrician’s primary patients. According to the textbook’s many authors, the obstetrical profession had been long seeking this goal, and they are obviously pleased to announce that has been achieved through the miracle of new medical technology.

As a brief historical aside, I must report that the authors apparently did not have the last word on the information presented in this edition. In the index of the 20th edition, under the letter C, is an entry that reads “Chauvinism, pages 1- through 1,547”. No doubt an unauthorized addition was made by an anonymous print shop employee.

 

~§ 1934 “The Committee on Maternal Welfare of the Philadelphia County Medical Society (1934) expressed concern over the rate of deaths of infants from birth injuries increased 62% from 1920 to 1929”. This was simultaneous with the decline of midwife-attended birth and the increase in routine obstetrical interventions, due in part to the influence of operative deliveries. Dr. Neal DeVitt, MD, a 1975 doctoral thesis “The Elimination of Midwifery in the United States — 1900 through 1935

 

~§ 1925 “… increasing mortality in this country associated with childbirth and the newborn is not the result of midwifery practice, and that, therefore, …their elimination will not reduce these mortality rates”, [1924-A; Dr. Levy, MD; p. 822]

 

~§ 1937 “Though we cannot make an exact comparison between the maternal mortality in the United States and that in European countries, we can at least make a rough comparison. All who have studied the problem agree that the rate for Holland, Norway, Sweden, Denmark is far superior to our own.

 

Why?  … it must be due to a difference in the patients themselves and differences in the way that pregnancy and labor are conducted in the two regions.” [1937-A Into the Universe; Dr Guttmacher, MD] p. 133-134

 

~ 1937 “What about the conduct of labor in the two regions? Here is where the major differences lie. In the first place, … at least 10 percent of labors in this country are terminated by operation. In the New York Report 20 percent of the deliveries were operative, with a death rate of more that 1 in each 100 of the operated, and 1 in 500 of those who delivered spontaneously. ” [1937-A Into the Universe; Dr Guttmacher, 1937]

 

~§ 1937 “Let us compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. In Sweden the [operative] interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland ….. it is under 1 percent.” [1937-A]

 

“What is responsible for this vast difference in operative rates? … Analgesics [narcotic drugs] and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted.

 

And midwives are trained to look upon birth as a natural functions which rarely requires artificial aid from steel or brawn. [1937-A]

 

 

Medical politicians had three primary goals associated with the plan to deconstruct the profession of midwifery and reassign its function to the medical profession. They were to improve medical school education through dramatic improvement in clinical training of medical students; to promote the obstetrical profession’s reputation and increase the economic compensation for services rendered by obstetricians. In the words of obstetricians of the era.

~ ¨1915 “Obstetrics is the most arduous, least appreciated, least supported, and least compensated of all branches of medicine”. [Dr. Moran, 1915]

 

~ ¨ 1913 “Legalizing the midwife will …work a definite hardship to those physicians who have become well-trained in obstetrics for it will have a definite tendency to decrease their sphere of influence.” [Huntington, MD; 1913]

 

~§ 1911 “In general, …the medical schools in this country and the facilities for teaching obstetrics are far less that those afforded in medicine and surgery;  ..yet young graduates who have seen only 5 or 6 normal deliveries, and often less, do not hesitate to practice obstetrics, and when the occasion arises to attempt the most serious operations.” 1911-B; Williams, MD p. 178

 

 

@@ ?? @@  Usually someone who wanted to expand an existing business has to start by raising “capital” upfront, either by finding investors or getting a big bank loan. Whether or not investors and bankers were willing to put out a substantial amount of money depended on what they thought your changes were for paying it back. Unfortunately, when an eager entrepreneur was asking a private bank or investor to front a couple hundreds of thousands so you could to transform your tiny 2-10 bed facility into a regional general hospital, the answer would inevitably be “no”.

Orphan  However, in the world of organized medicine which sees “regulatory capture” government agencies, such as state health departments and medical boards, the actual truth is irrelevant. The politics of ‘regulatory capture’ is when special interest groups, in this case professional lobbying groups for organized medicine, become so influential over the actions (often inactions) of the agencies that are suppoed to be regulating the practice of medicine and guard the public safety, that our “watch dogs” not have become toothless, but are actually part of the problem, far more afraid of triggering the rath

Orphan  (insert excerpt from MD-statistician for Met Life Insurances in 1932 about the midwifery care provided by Frontier Nursing services saving that if American childbearing women received the same quality of midwifery care, it would save the lives of 10,000 mothers annually and 60,000 babies (total prevented death of 70,000 annually)