Word count 3131 Jan 2025
Chapter three: draft ~ The Obstetrical Franchise In America: The 20th Century Gender War btw Midwifery and Obstetrics (spoiler alert – obstetricans won, midwives and childbearing women lost!)
The Obstetrical Franchise Crosses the Pond – Having a Baby in the New World
When Europeans migrated to the New World during the 16th and 17th centuries their beliefs traveled with them, including the idea that childbearing was dangerous. However, the kind of science-based medical care that was available in Europe did not reach the US until the late 1800s. Even then scientific medical practice was confined to big cities of the Eastern seaboard and was still 40 years shy of discovering antibiotics, safe blood transfusion, safer anesthesia and access to effective birth control.
The dangers of childbirth at the end of the 19th century were depressingly similar to those of the Middle Ages — diseases of poverty & deprivation, malnutrition, poor public sanitation, contaminated water, polluted air, overwork, ignorance, prejudice, forced childbearing (with frequent, close-spaced pregnancies), lack of access to medical services, and the inability of medical care to help. In the late 1800 and early 1900s as many as 10 out of a 100 babies died during the first month of life.
However, the turn of the century in the United States also brought many important and dramatic changes. Anything called ‘scientific’ was hot, city living was ‘in’, education and incomes were up, people began to expect more and to be able to pay for medical services. The change in maternity care during the first three decades of the 20th century was nothing short of radical. Most of these changes were based on the assumption that childbirth, even in healthy women, was dangerous and required the services of a medical professional.
By the time obstetrical medicine landed in America, the European hospital-based tradition had bifurcated obstetrical practice further and further away from its roots in midwifery and physiologic process. The new science of obstetrics, now freed from traditional restraints and physiological management, seem to offer unlimited new possibilities. The basic hypothesis by the medical profession was both straightforward and self-referent: If “uneducated” (in the formal sense of university affiliation) female midwives did an OK job of providing maternity care to childbearing women, then male, university-educated physicians would be able to do a vastly superior job. In modern economic terms, obstetrics would be called a “value-added” service, which built upon and improved on the traditional knowledge base of midwifery, or, if you will, that a doctor always could do a midwife one better.
Irrational Enthusiasm, Obstetrical-style
Society was soon infused with the ‘irrational enthusiasm’ of the obstetrical profession. Newspapers ran regular headlines on the “medical miracles” of the new obstetrics and the promise of “painless childbirth”. In an amazingly short time, local, state and federal governments all became part of the echo chamber for this “new and improved model” of maternity care, which depended on eliminating midwives and replacing them with newly graduated obstetrical surgeons and newly opened hospital maternity wards.
Quite conveniently, the medical profession had forgotten all about having learned its own discipline by appropriating the intellectual property of midwifery. Instead of respect for midwives and a spirit of cooperation, American physicians in the early years of the 20th century had convinced themselves that midwives in the US, who were unschooled in ‘scientific obstetrics’ were outdated and dangerously ignorant. From this perspective, the traditions of midwifery itself — physiologically-based care and spontaneous birth — were defective. In the early 1900s influential members of the profession redefined physiological management to be unscientific and ‘outdated’. According to this opinion, midwives were downright dangerous and no longer to be tolerated. Organized medicine had little trouble convincing the lay public that the new ‘scientific’ practice of obstetrics was safer for the baby and easier on “the little woman”.
As physicians were already aware, maternity care was an excellent way to increase their general practice of medicine thru referrals to them by satisfied customers – the new mother and her whole family. An 1820 medical publication advised physicians that: “Women seldom forget a practitioner who has conducted them tenderly and safely through [childbirth]” “It is principally on this account that the practice of midwifery becomes desirable to physicians. It is this which ensures to them the permanency and security of all their other business.” [note: use of the word ‘midwifery’ in this context refers to the general discipline of normal maternity care, not to care as provided by midwives]
Reiterating this theme nearly a hundred years later, the physician-authors of paper published in the Boston Medical & Surgical Journal, [Feb 23, 1911, page 261] stated:
“We believe it to be the duty and privilege of the medical profession of America to safeguard the health of the people; we believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth.
The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public.”
A famous obstetrician of the era (Dr. Joseph DeLee, 1915), remarked: “If the profession would realize that parturition [childbirth], viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention.” [Dr Joseph DeLee, MD 1915-C; p.117].
Dr DeLee was famous (or perhaps infamous!) for insisting that childbirth, from the mother’s standpoint, was about as “natural” as falling on a pitchfork. He likewise insisted that every baby’s head was subjected to pathological forces during even the most normal labor by being repeated bashed into the mother’s “iron” perineum. The take-home message in 1910 was that a “generous” episiotomy saved both mother and baby from the malevolent forces of her iron (i.e., intact) perineum and that the routine use of forceps ‘saved’ the baby from being battered and bruised as it was pushed down thru an intrinsically dangerous birth canal by the unpredictable forces of nature.
“For the sake of the lay members who may not be familiar with modern obstetric procedures, it may be informing to say that care furnished during childbirth is now considered, in intelligent communities, a surgical procedure.” [1911-D, p. 214]
‘The parturient [laboring woman] suffers under the old prejudice that labor is a physiological act,’ … and the medical profession entertains the same prejudice, while as a matter of fact, obstetrics has great pathologic dignity — it is a major science, of the same rank as surgery”. [Dr. DeLee, 1915-C; p. 116]
The Ripple Effect of Birth as a “Surgical Procedure” – A Tsunami of Change
Defining childbirth to be a “surgical procedure” vastly expanded the role of obstetrical education and required a constant stream of “clinical material” (teaching cases) so that medical students could learn and practice these surgical principles and techniques. Professors of obstetrics insisted that every time a midwife attended a normal birth, it was an appalling “waste of obstetrical material”, which deprived medical students of a valuable educational opportunity.
“Of the 3 professions — namely, the physician, the trained nurse and the midwife — there should be no attempt to perpetuate the latter [i.e. midwife] as a separate profession. The midwife should never be regarded as a practitioner, since her only legitimate functions are those of a nurse ….” [Dr Edgar; 1915-A, p. 104]
“The nurses should be trained to do all the antepartum and postpartum work, from both the doctors’ and nurses’ standpoint… In this plan the work of the doctors would be limited to the delivery of patients, to consultations with the nurses, and to the making of … physical and obstetrical examinations.” [emphasis added; Dr. Ziegler, 1922-A;p. 413]
“The doctor must be enabled to get his money from small fees received from a much larger number of patients cared for under time-saving and strength-conserving conditions; he must do his work at the minimum expense to himself, and he must not be asked to do any work for which he is not paid the stipulated fee. This means … the doctors must be relieved of all work that can be done by others—nurses, social workers…” [1922-A; Dr. Ziegler, MD; p. 412]
Birth as surgical procedure also changed the fundamentally nature of medical education and scientific inquiry. Physician researchers no longer studied the physiological management of labor since doctors did not attend labors (that was done by nurses). And if a problem arose during labor it was a foregone conclusion that the answer would be drugs or surgery. Once normal childbirth becomes a surgical procedure there is no reason for medical educators to teach, or for medical students to learn, the principles of physiological management that are the foundation of the traditional and contemporary practice of midwifery.
Historically these physiological methods included “patience with nature”, continuity of care, the full time presence of the primary caregiver during active labor, one-on-one social and emotion support, an upright and mobile mother during labor, non-drug pain management (such as walking, therapeutic tough, showers and deep water), right use of gravity during labor and vertical positions during birth.
“…in the US, physicians had little contact with midwives and never learned their useful traditions, among them, patience with nature.” [Dr. Neal DeVitt, MD, 1975]
By changing uncomplicated childbirth in healthy women from a normal biological function that needed little in the way of “doctoring”, into a pathological event requiring surgical skills (or as one physician described it “the artificial aid of steel or brawn”), the physician’s role became more central to childbirth than the mother’s. In the eyes of organized medicine, this elevated the physician from a ‘helping’ role, who merely served childbearing women (i.e., ‘woman’s work’), to that of a surgeon performing a surgical “procedure” and for which he received a large fee, equivalent to that of gallbladder surgery or a hysterectomy or any other operation.
Similar to surgeons performing surgery, obstetricians had (and have) no part in the “normal” care of the patient before or after the ‘operation’, now considered ‘pre-op’ and ‘post-op’ Instead they would only be responsible for the ‘surgical procedure’, while all other aspects of minute-by-minute care would be done by others – nurses and other low-paid assistants who work under the direction of the doctor, providing care for both pre and post-op.
Great Expectations Contrast with Poor Performance
Another part of the campaign against midwifery was the need to defend the poor reputation and abysmal safety record of obstetrics at the turn of the century in the US. {Note from author: add description and statistics from paper on the Decline of Maternal Mortality in Sweden due to community midwifery}
new statistical support According to vital statistic records and eye-witness reports from physicians of the day, the US had one of the worst records of maternal-infant death in the developed world. The harder doctors tried to medically control normal birth and improve on Mother Nature through the expanded use of drugs, medical interventions and operative deliveries, the higher the rate of maternal and infant mortality and birth injuries rose.
One obstetrician scolded his colleagues for this embarrassing situation, stating that “Maternal mortality in this country, when compared with certain other countries, notably England, Wales and Sweden is … appallingly high and probably unequaled in modern times in any civilized country”.
Another obstetrician (Dr. Hardin) reported that “in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile.” [1925-A, p.347].
A third physician reporting on maternal mortality, stated that “…during 1913 about 16,000 women died..; in 1918, about 23,000…and with the 15% increase … the number during 1921 will exceed 26,000.” [Note: Out of approximately 1.5 million births] [Dr. Ziegler, 1922-A]
In 1937 the founder of the present-day Guttmacher Institute in NYC remarked that:
“All who have studied the problem agree that the rate [of good outcomes] for Holland, Norway, Sweden, Denmark is far superior to our own. Why? … it must be due to differences in the way that pregnancy and labor are conducted in the two regions.” “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 than 1 in each 100 of the operated, [compared to] 1 in 500 of those who delivered spontaneously. .” [1937-A, Dr Guttmacher, p. 133-134
Clinical Material, the ‘Flexner Report’ and the ‘Midwife Problem’
1910 was definitely not a good year for the obstetrical profession, as it was further humiliated by the Flexner Report, a study of American medical schools published and funded by the AMA. The Flexner report severely criticized the lack of clinical training in US medical schools, especially as contrasted with the hands-on obstetrical training that had been available on ‘The Continent’ for centuries. This long tradition of clinical training was primarily the result of those big charity hospitals all across the European continent that seamlessly integrated teaching with treatment. But this system of public institutions providing both service and education had not made it to the US, leading our “best and brightest” students (at least those from wealthy families) to get their medical education in Europe. Due to the obvious deficiencies of our system, the majority American physicians were far less trained than midwives. Nonetheless they performed dangerous operative deliveries on a regular basis, to the detriment of their patients, thus contributing mass to the idea that normal birth was damaging.
“In general, … the facilities for teaching obstetrics are far less than 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.” [Dr. J.W.Williams, 1911-B p. 178]
This described the typical training of the era, in which medical students only “observed” deliveries in an amphitheatre-style setting with rare (or no) occasion to obtain hands-on practice in the use of forceps or surgical procedures that they would use after graduation. This resulted in dangerously poor obstetrical care, ill-conceived operative interference and preventable deaths.
“The generally accepted motto for the guidance of the physician is ‘primum non nocere’ (in the first place, do no harm), and yet more than three-quarters of the professors of obstetrics in all parts of the country…. stated that incompetent doctors kill more women each year by improperly performed operations than the … midwife….”
“Why bother the relatively innocuous midwife, when the ignorant doctor causes many more absolutely unnecessary deaths”. [1911-B; Dr. Williams; p.180]
“In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives’”. [Dr. Ira Wile 1911-G, p.246]
Inferior medical training as contrasted with European medical schools (and pointed out in such unflattering terms by the Flexner Report!) lead one of the founding fathers of the 20th century obstetrical profession and author of Williams Obstetrics (the ‘bible’ of obstetrical textbooks) to write:
“ ….. 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.” [emphasis added, Dr J. Whitridge Williams, 1911-B]
“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 …. [1911-C, p. 207]
The low esteem & poor reputation of obstetrics among the public resulted in a burning desire to rectify the situation and reverse the fortunes of obstetricians as soon as possible. A desperate effort by organized medicine to quickly increase the “clinical material” (teaching cases) available to medical students was a major motivator in the plan to eliminate midwives. Literature of the day contained the following comments on this topic:
“When we recall that abroad the midwives are required to deliver in a hospital at least 20 cases under the most careful supervision and instruction before being allowed to practice, it is evident that the training of medical students in obstetrics in this country is a farce and a disgrace.”
“It is generally recognized that obstetrical training in this country is woefully deficient. There has been a dearth of great obstetrical teachers with proper ideals … but the deficiency … in obstetrical material for teaching purposes has been even greater. It is today absolutely impossible to provide [clinical] material.” [1912-B, p. 226
“It is then perfectly plain that the midwife cases, in large part at least, are necessary for the proper training of medical students. If for no other reason, this one alone is sufficient to justify the elimination of a large number of midwives, since the standard of obstetrical teaching and practice can never be raised without giving better training to physicians.” [1912-B, p.226]
“I should like to emphasize what may be called the negative side of the midwife. Dr. Edgar states that the teaching material in New York is taxed to the utmost. The 50,000 cases delivered by midwives are not available for this purpose. Might not this wealth of material, 50,000 cases in NY, be … utilized to train physicians?” [1911-D, p 216]
In order for medical politicians of this historical era to have pursued this dubious course of action, several crucial facts had to be ignored. First, that childbearing itself in healthy women is not fundamentally dangerous and does not routinely benefit from surgical skills. Second that it was poverty, overwork and forced childbearing that were the genuine problems facing mothers and babies of that time period and which contributed to an alarming rate of death and disability. Third, their actions failed to account for the serious harm — including death for both mother and baby — which could and did result from the routine use of medical interference. Forth and most unfortunate of all, these harmful interventions did not address the underlying health problems of poverty and overwork or contribute to the greater goals of public health in a more profound and long lasting manner. The great improvement in maternal-child health that has occurred over the course of the 20th century is primarily the result of an increased standard of living — sanitation, education, a better diet, adequate housing, improved working condition, appropriate access to medical care when needed and the safety net of social programs combine with wide-spread availability of effective contraception. Only a tiny portion of this improvement can be attributed solely to obstetrical interventions. In many instances, the underlying cause of problems later “cured” by obstetrical procedures, were being actually caused by poverty and exploitation and would have been more properly been prevented than medically ‘treated’.
