Original source file is <Commentary-DrZiegler-presentation-Am-Public-Health Assoc 1921> —>
Gender-prejudice as root of all evil — the medical profession’s gender bias against women as the ‘weaker sex’ included obstetricians as a convoluted form of “guilt by association”. Childbirth was seen as “women’s work”, in which only members of the female gender got pregnant and gave birth and these childbearing women were only attended by female practitioners. As a result, all aspects of was described
Editor’s Overview & Background — American Obstetrics early 20th century
The basic history of American obstetrics is well-documented but not very well- known by other branches of medicine or the American public. The only exception are midwives, as the relationship between obstetrical medicine and midwifery continues to be adversarial and practicing midwives continue to be discriminated against by individual obstetricians, obstetrical organizations, hospital policies, and organized medicine.
By 1910 the American obstetrics, which now considered itself to be a surgical specialty, essentially redefined and replaced the category of “normal childbirth” with a definition in which pregnancy and childbirth were a dangerous quasi-pathological process, characterized by the obstetrical profession as “a nine-month disease that required a surgical cure“. This functionally eliminated the medical category of normal childbirth for members of the obstetrical profession.
Doctors wrongly assumed that replacing the non-interventive care of midwives with the routine use of obstetrical interventions would make normal childbirth intrinsically safer. This included Twilight Sleep drugs during labor and conducting normal childbirth as a surgical procedure “performed” in an operating room by an obstetrically-trained doctor on labor patients rendered unconscious under chloroform or other general anesthesia.
The negative impact this had on childbearing women, who did not need, want or benefit from the routine use of surgical procedures such as episiotomy, forceps and manual removal of the placenta was beyond comprehension. This was the most profound change in childbirth practices in the his- tory of the human species.
As the obstetrical profession replaced the non-interventive and supportive measures traditionally provided by midwives with invasive procedures, such as episiotomies, forceps deliveries and reaching up into the unconscious mother’s uterus to extract the placenta dramatically, all increased the level of injury to both mother and baby related to childbirth. Between 1916 and 1912 mortality
During the first decade of the 20th century, American obstetricians choose to drastically depart from the traditional practice of obstetrics in Europe. Historically, obstetricians were only called on when there was a serious childbirth complication that required invasive interventions, such as a breech extraction, forceps or a Cesarean.
An irrational and inexplicable prejudice by the human species in which males defame and discriminate against the female of the species. According to historians, this irrational trait traces back at least 7,000 years.
When the irrational behavior of early 20th century obstetrics toward women as midwives and women as labor patients is explored, the inevitable conclusion is an intense gender-based prejudice by the medical profession against the female gender.
This is immediately in the vocabulary used by doctors in the early 1900s when referring to themselves and one another. They eschewed the title “doctor” and uniformly referred to themselves and one another as “medical men”. this instantly communicated as an established “fact” that obviously women could not be medical doctors simply because they were not male!
But I don’t mean to trivialize the extremely important issue of gender prejudice by focusing on vocabulary. As described earlier, obstetrical practices in the US were light years alway from the way normal childbirth was treated in Western Europe, where professional midwives provided care backed up by obstetricians. American obstetrics was instead organized around getting rid of midwives.
But historically detrimental issue is that obstetricians replaced a safer system of physiologic support for normal childbirth that included medical-backup for complications, with the universal application of an invasive, always distressing, medically-dangerous and often physically brutal system that double the already high rate of maternal death. How could this happened?
Why were obstetricians so seemly vicious in regard to their scorched-earth, anti-midwife politics and so extremly invasive in regard to their “business as usual” childbirth practices, in which they defined childbearing as a quasi-pathology and childbirth “is now, in intelligent circles, a surgical procedure”?
It would be easy to dismiss obstetrically-trained “medical men” as raging, ill-intentioned misogynists who hated women and took great sadistic pleasure in making their women-patients suffer. But factually that would be a serious misunderstanding, and do nothing to help us understand this era of our history, and no doubt make it hard to improve the care currently provided to healthy childbearing women.
Unfortunately, I think by pessimism about fate of midwifery in the US. Seems to me that nothing short of a nuclear winter would change the professional relationship between the well-fi- nanced and politically influential American College of Obstetrics and Gynecologists ACOG joined and enthusiastically embraced the AMA’s “Scope of Practice Partner- ship” link here and continuing their efforts to defame and suppress the practice of midwives.
In the meantime, the so-called “economic competitions” of midwives describe hard working women who are chronically sleep-deprived, are frequently are up most or all of the night and then being responsible for getting their kids off to school when they get home. It’s never been a “fair” fight between midwives as individuals and the midwifery profession when either one is being targeted by the well-financed political campaigns of organized medicine.
The purpose of reporting on the history of obstetrics and the nature of its relation- ship with the practice of midwives and its impact.
As an L&D nurse and now as a midwife, I have been working in both kinds of care (obstetrics and modern midwifery after obstetricians) system as well as studying read- ing the historical records for more than 40 years, have become something of an “idiot savant” of 20th obstetrics and midwifery, and based on historical records and direct experience, I am personally am 100% sure that neither misogyny or sadism was the reason for this era of institutionalized misery that was till going strong when graduated from nursing school and was working as an L&D nurse in the early 1970s.
Obstetrical department protocols still included Twilight Sleep drugs, general anesthesia, rou- tine episiotomies, use of forceps, and the manual removal of the placenta. The only good news is that antibiotic drugs existed to that prevented newly-delivered mothers from dying from infection.
This is at the very root of overwhelming and unfortunately successful effort by the obstetrical profession in the United States to both mfry and OB status – the medical profession likened attendance at CB as no more a legitimate practice of medicine than a terrier dog sitting outside a rat-hole waiting for the rat to escape
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Commentary on content of Dr. Ziegler’s presentation
to the American Public Health Association 1921
Small excerpts may be interceded into the content of Dr. Z’s actually paper but this 10-page of comments on various topics and background info should be a standalone essay
Editor’s Overview & Background
To better understand Dr. Ziegler’s message to the public health community, a little background information will be helpful.
During the first decade of the 20th century, American obstetricians choose to drastically depart from the traditional practice of obstetrics in Europe. Historically, ob- obstetricians were only called on when there was a serious childbirth complication that required invasive interventions, such as a breech extraction, forceps or a Cesarean.
However, in 1910 American obstetricians defined obstetrics to be a new surgical specialty whose patient demographic included normal childbirth in healthy women as well as complicated cases that required surgical interventions. This was based on statements by the obstetrical profession that childbirth was an inherently pathological process. This included a public description of pregnancy as a “nine-month disease” that required a “surgical cure”. This official conclusion by the American obstetrical pro- fession dramatically and drastically re-defined normal childbirth in the United States.
From a scientific perspective, childbirth in a healthy woman is normal biological event in she actively “gives birth”. However, the new obstetrical concept saw normal birth as a potentially dangerous medical condition. This turned childbirth in America into a surgical procedure called “the delivery”, which was to be performed by doctors on the body of anesthetized women. This was the most profound change in childbirth services in the history of the human species.
After rendering these healthy labor patients unconscious with chloroform anes- thesia, the doctor would routinely perform series of sterile surgical procedures. This began by cutting an episiotomy and inserting the blades of the forceps into the moth- er’s vagina on each side of her baby’s head.
Then the doctor would ask the delivery room nurse to provide a very forceful and dangerous form of “fundal pressure” designed to press the baby’s head farther down in the mother’s pelvis. This required the nurse to stand on a foot stool next to the de- delivery table and use her own body weight to push down as hard as she could on the top (fundus) of the mother uterus. This facilitated the doctor’s use of forceps to extract the baby from its unconscious mother’s body.
After delivering the baby, the doctor manually removed the placenta by reaching a gloved hand up through the mother’s vaginia into her uterus, detaching the placenta from the uterine wall and then pulling it out in his hand. The last in this series of sur- gical procedures was suturing of the episiotomy incision. Then L&D nurses moved the still profoundly unconscious mother off the delivery table and on to a stretcher and took her to a recovery area to be watched until she was conscious again.
These highly-invasive surgical procedures, combined with the biologically stress of general anesthesia, became the “standard” many decades before the discovery of antibiotics. During this time, the single most frequent cause of maternal death in the US was sepsis – fatal infections associated with being hospitalized, anesthetized and/ or having a surgical procedure.
What Dr. Ziegler believed were the biggest problems and his ideas for solving them so he began with a with double-barreled topic that most OBs — 99% of whom were male — would rather not think about – the high MMR in the US compared to oth- er comparably wealthy developed countries and general role of the female gender in society and as obstetrical patients and as midwives.
This extraordinary statement by Dr. Ziegler in 1921 more fully acknowledged the asymmetrical gender-related burden born by women than any contemporary statement I’ve ever read. He really understood what it meant to be a childbearing woman in the early 1920s (before the discovery of antibiotics). Equally important, he both acknowledged and appreciated what women, as a gender, offered to society and what they sacrificed as wives and mothers in carrying out their biological duties:
“Each year in this country about two and half million women, less than 2.5 % of the total population, are charged with the responsibility of the nation’s childbearing; each for herself and her dependents, solely upon her own resources must bear the physical and economic burden associated therewith with what risk to her life and how fruitless and useless much of her burden bearing is, we learned from more than the 2000 ma- ternal deaths and 30,000 infant deaths each month ….”
The big blue “elephant in the room” that doctors and the American Medical Association never wanted to talk about or publicly acknowledge. The immutable fact was the vast majority (over 80%) of all childbearing families could not afford the typical ob- stetrical fee for childbirth.
This was a historic clash between the economic and realities of the majority of America’s childbearing families and the economic expectations of the obstetrical profession, as a surgical specialty, to be compensated for performing the “surgical procedure” of “delivery” at the same level as general surgeons were compensated for performing tonsillectomies, appendectomies, gallbladder operations and reducing compound fractures.
fragment –> ? expected that they would be financially compensated for the ?
As a result, lower- and middle-class mothers were being attended by midwives, much to the consternation of the obstetrical profession. But even more to the point, the obstetrical profession objected to the economic competition of midwives, who attended from 40% to 60% of all births. Having half of all births attended by a competing profession was an economic was a disaster for obstetricians, who said they could not earn a “living wage” from the meager number of births they were called to attend.
In addition to the irritating economic competition with midwives, the obstetrical profession believed that any birth attendant who hadn’t graduated from medical school (i.e. midwives) was incompetent, therefore childbirth services should always and only be provided by MDs.
For obviously good reason, a majority of childbearing families could not afford to pay for MD services.
Dr. Ziegler understood that this disparity between the average income of working families and what obstetricians expected to receive as a professional fee were light years apart and likely to stay way. So, Dr. Ziegler became very actively involved in founding a new type of maternity hospital in Pittsburg, Pennsylvania.
The Magee Women’s Hospital was supported by private donations and patient fees, and its obstetrical staff were salaried hospital employees. As a result, Magee Women’s Hospital and Dispensary (i.e. outpatient clinic that also provided home birth services) was able to provide obstetrical care for whatever amount of money the patient’s family was able to pay, including the care of medically indigent patients who had no money.
Historically, the AMA has always insisted that MDs should never, under any circumstances, allow themselves to become an employee of another person or organization. The very nature of having a state-issued license to practice medicine was to always and only be “independent contractor” that only provided care on a “fee-for-service” basis – no fee, no service!
However, in order for the Magee maternity hospital to work the doctors on staff needed to be salaried employees, a circumstance that the AMA was so violently op- posed to that local representatives of the American Medical Association took legal ac- tion against Dr. Ziegler unprofessional conduct. This was defined by the AMA as sup- porting a “policy which is detrimental to the public and the profession” and “taking patients which are able to pay private physician; For taking patients which had already engaged a physician; And for soliciting patients”.
But unfortunately for the AMA, they were barking up the wrong tree. By the stan- dards of the day, Dr. Ziegler was one of the “good guys”. He was relentlessly outspo- ken about the “appallingly high maternal mortality rate” ref Dr. Howard in the US when compared to other developed countries.
Influential obstetrical leaders of the time all agreed that high level of preventable maternal deaths in the US was the result of inadequate and poor-quality medical school training in obstetrics, combined with the in- ability of many women with complicated pregnancies to pay for the desperately- needed obstetrical care, compounded by the very low social and economic status as- sociated with providing childbirth-related care.
From Time Immemorial, normal childbirth services have been provided by midwives. During all those centuries, attending births was likewise stigmatized and dismissed as “women’s work” by a biased and misogynist medical profession. This stigma also extended to obstetricians who attended normal births. Many members of the medical profession expressed their distaste and disrespect for this kind of “low-class” endeavor by saying they could not 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. ref: Dr. J. Whitridge Williams, 1911-B
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Unfortunately, this visually disturbing idea of waiting before a “rat hole” (i.e. a woman’s vaginia) communicates both the depth, and at times the depravity, of the op- position both to midwives and to the new surgical specialty of obstetrics. The new surgical specialty suffered from the fact that obstetricians provided care to the female gender, that they were in economic completion with the female gender as midwives. The extremely high rate of maternal mortality the US due to poor quality of medical education in the field of obstetrics made all this even more embarrassing.
At risk of being accused of beating a “dead horse”, I must interject here the gen- der-related issue of the recent US Supreme Court ruling that overturned Roe V. Wade, in which five men decided it was their divine destiny to pass laws that would control of women reproductive functions irrespective of the woman’s own right to bodily in- tegrity or the fact that the pregnancy was the result of rape or that it’s continuation risked the woman’s life. “The more things change, the more they stay the same”.
Dr. Ziegler’s most immediate goal was to reduce the large number preventable maternal deaths by dramatically improving obstetrical education in the United States. But he also realized that the big long-term problem for the obstetrical profession was economic – the fact that people in general, and other members of the medical profes- sion in particular, had a negative and demeaning view of childbirth services as “women’s work”.
As long as the public saw the obstetrician as merely a “man-midwife”, the doctor’s social status would continue to be defined as “woman’s work. As a result, his income would be trapped at a level barely above that of the midwife’s typical fee of a few dollars.
This put obstetrics at the very bottom of the social and economic barrel, both in status and income, as people were not willing to pay obstetricians at the same level as other medical and surgical specialties.
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The general population was very familiar with normal childbirth, since 95% of all births occurred at home. People knew from personal experience that it was the woman herself who labored and gave birth, while the doctor stood by “just in case”.
They didn’t see the obstetrician who ‘caught’ the baby, as having performed a great service, certainly not when comparison to a doctor who performed a surgical operation. As long as childbirth was seen as a normal bodily function of female biology attended by other females, the obstetrical profession would not be able to achieve the desired status and “appropriate” economic compensation they sought for attending births.
So, the second big goal was to dramatically increase the income of obstetricians. It was assumed that the quality of obstetrical care would be substantially improved if obstetricians were more respected and more fairly compensated.
Influential leaders saw midwives as the obvious and immediate barrier to achieving both of these goals. To begin with, the many hundreds of midwives that attended thousands of births every year in the US were seen depriving the medical schools of the very valuable “teaching cases” or “clinical material” that would otherwise would have been used to teach obstetrical practices to thousands of medical students every year. Midwives were described as by “wasting” valuable “obstetrical material” (i.e. teaching cases), thus inferring that the presence of midwives was to blame for maternal deaths.
Therefore, midwives were the single biggest impediment to improving medical education, therefore indirectly responsible for country’s disproportionately high MMR.
Influential obstetricians concluded that medical schools needed to do a much more effective job of teaching obstetrics by providing “hands-on” or “clinical” training in obstetrics to all its medical students. Clinical training had long been part of a medical education in the big regional hospitals of Europe, but at the time, the US didn’t have many large general hospitals to provide indigent patients as “obstetrical material” (i.e. teaching cases).
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The obvious place to begin was by eliminating the “midwife problem” which real- istically wasn’t about midwives pe se, but the fact that the system that what worked for midwives made it hard for medical school to provide enough “teaching cased” for clinical training and even worse was the economic disaster that that care of midwives inadvertently generated for the obstetrical profession.
Leaders in the obstetrical profession saw this as a two-fold plan to dramatically improve medical education in obstetrics and greatly increase the income of practicing obstetricians. Eliminating the ability of midwives to legally practice would provide the necessary “obstetrical material” for the clinical training of medical students, assuring that they delivered at least 50 (or more) labor patients before graduating from medical school.
The second part of the goal was to greatly improve the social and economic status of practicing obstetricians by separating themselves from midwives and continuing to widen the social gap between themselves and midwives. This began with a PR campaign in newspapers, women’s magazines and radio programs that demonized and defamed midwives as an ignorant and dangerous type of caregiver, and then altogether eliminating the economic competition by making it illegal in most states for midwives to practice midwifery.
The blatent hostility agasint midwives by many doctors was the opinion that midwives get in the way of because the majority of American families could not afford to pay for childbirth services to make it profitable.
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This would dramatically increase the number of maternity patients available as “teaching cases” for medical students and to eliminate the both the numerical eco- nomic competition and the fact that people generally paid a woman far than a man for the same servcies, a fact that was tanked the and stabilize professional fees of ob- stetricians improved obstetrical training by.
then making obstetrical services affordable to the general population by having such services provided by obstetrically trained doctors where were employed by a private supported by public charities or public hospitals receiving state or local funds.
This idea was the absolute anathema of organized medicine, which is en- trepreneurial free-enterprise (no federal money under any and all circumstances, in- cluding rejection of the Sheppard-Towner Act of 1921- & 1927 (repealed in 1929) which provide matching funds to the state for maternal-infant services) and fought tooth and nail, up to and including going after Dr. Ziegler professional as a turn coat
As a result, midwives and general practice doctors were attending the majority of births in the US.
Editor’s Note ~ Sorry but some of the original text didn’t get copied.
???? normal childbirth in the babies of low and middle-class families were being delivered by midwives obstetrically-managed
This document, originally written for other obstetricians, required some familiarity with the topics to fully understand what rearranges the original material by content to make ????
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Note-2-self –>
