Medical Education and the Campaign to Abolish the Midwife ~ #3

by faithgibson on February 21, 2015

in Historical Childbirth Politics 1820-1980, Historical Publications

Third in a 5-part series

Medical Education and the Campaign to Abolish Midwifery

Only by being familiar with obstetrical science and education in the US in the early 1900’s can one reasonably evaluate the obstetricians’ campaign to eliminate the midwife. Obstetrical education in the early 1900s in United States was not primarily based on clinical training as it is today. Instead of actual hand-on practice over the course of several years, educators depended textbook learning, lectures by professors and a very limited number of “observations” of care rendered by others.

~ “The story of medical education in the country is not the story of complete success. We have made ourselves the jest of scientists through out the world by our lack of a uniform standard. Until we have solved the problem of how NOT to produce incompetent physicians, let us not complicate the problem by attempting to properly train a new class of practitioners. The opportunities for clinical [i.e. “bedside”] instruction in our large cities are all too few to properly train our nurses and our doctors; how can we for an instant consider the training of the midwife as well?” [1911-C, p. 207]

Dr. Whitridge Williams, the original author of “Williams Obstetrics” was highly critical of this situation:

~ “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 3/4 of the professors of obstetrics in all parts of the country, in reply to my questionnaire, stated that incompetent doctors kill more women each year by improperly performed operations than the … midwife….” 1911-B; Williams, MD p.180

~ “A priori, the replies seem to indicate that women in labor are safer in the hands of admittedly ignorant midwives that in those of poorly trained medical men. Such conclusion however, is contrary to reason, as it would postulate the restriction of obstetrical practice to the former (midwives) and the abolition of medical practitioners, which would be a manifest absurdity.” [1911-B; Williams, MD]

~ “The training of midwives in Germany, where they are required to spend 6 months in a government obstetric hospital under the instruction and supervision of trained obstetricians, is far superior to that which the great majority of physicians receive in this country before graduation.” [1925-A]

~ “In all but a few medical schools, the students deliver no cases in a hospital under supervision, receive but little even in the way of demonstrations on women in labor and are sent into out-patient departments to deliver, at most, but a half dozen cases. 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 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] {emphasis added}

~ “If such conclusions are correct, I feel that …[we must] insist upon the institution of radical reforms in the teaching of obstetrics in our medical schools and upon improvement of medical practice, rather than attempting to train efficient and trustworthy midwives.” 1911-B; Williams, MD p.166

At the time, it was inappropriate to use private patients as teaching cases. This made the immigrant population and the other ‘low-class’ childbearing women cared for by midwives the ideal source for the scarce and much coveted “clinical material”.

~ “I should like to emphasize what may be called the negative side of the midwife. Dr. Edgar states that the teaching material in NY 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 gradually utilized to train physicians?” [1911-D, p 216]

~ “Another very pertinent objection to the midwife is that she has charge of 50 percent of all the obstetrical material [teaching cases] of the country, without contributing anything to our knowledge of the subject. As we shall point out, a large percentage of the cases are indispensable to the proper training of physicians and nurses in this important branch of medicine..” [1912-B, p.224]

Influential obstetricians considered midwifery training to be expendable, something to be exchange for the “greater good” defined by Dr. DeLee in his paper on “Ideal Obstetrics”. Bottom line to his articulated argument was that the improved abilities trained midwives who would in turn provide care to poor and working-class women did not count as much as the educational advantages that would elevate the obstetrical profession, who would then take over all the care of all childbearing women, either directly or by using the poor as teaching cases.

~ “It is, therefore, worth while to sacrifice everything, including human life to accomplish the (obstetric) ideal “. [DeLee; 1915-C]

Dr. DeLee: “We are asked to educate the midwife as a matter of expediency, to provide a little better care of the poor, the ignorant woman or foreigner and, we are told, though I do not believe it, that 40% of the women in American must have midwives. The 60% employing doctors are well-to-do — or at least, no paupers — educated and American.

Now I hope I will not be misunderstood… I …take second place to no man or woman in my regard for the poor, the ignorant, the foreign-born childbearing mother. But I have just as high regard for the well-to-do, the educated and the American woman and I must raise my voice against a measure which, I am convinced from 25 years of deep, close observation and study, will tend to jeopardize her health and life. While we may, by educating midwives, improve the conditions of the 40% [i.e., midwife-attended births], we will delay progress in ameliorating the evil conditions under which the 60% [physician-attended] now exist. For every life saved in the 40% we will lose many more in the 60%.

“Ideas and ideals are the hardest things in the world to establish, but once established they are impossible to eradication and they raise the plane of human existence. It is therefore, worth while to sacrifice everything, including human life, to accomplish the ideal. Knowing this I am willing … to close my eyes to what the midwives are doing and establish high ideals. Then all, poor and ignorant, as well as rich and educated — the 40% as well as the 60% will enjoy the benefits of improved conditions.

In all human endeavor improvement begins at the top and slowly percolates down throughout the masses. One man runs ahead of the crowd and plants a standard, then drives the rest up to it. Search history, biblical and modern, and this fact stands out brilliantly.” (emphasis added) [1915-C, Dr. Joesph DeLee, MD]

~ “Engelman says: ‘The parturient suffers under the old prejudice that labor is a physiologic act,’ and the 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”. [1915-C; DeLee, MD; p. 116 in TASSPIM]

Comments in 1975 by Dr. Neal DeVitt about the obstetrical philosophy of pathologic dignity given voice so eloquently by Dr. DeLee

~”The quality of obstetrics was hampered not only by the past failing of medical education but perhaps more so by the nature of the campaign to eliminate the midwife. To discredit the competence of the midwife as a birth attendant, obstetricians had argued that pregnancy, labor and delivery were not normal physiological processes but so fraught with danger that only an obstetrician could safely attend birth.” [DeVitt, MD; 1975]

[Note: This not only impinged on midwives and midwifery historically but by the 1970s, obstetricians, successful as they had been in abolishing independent midwifery, turned this same argument against the provision of maternity care by general practitioners and family-practice physicians. Through the influence of obstetricians on hospital policy-setting committees, not only midwives but family practice doctors have, by and large, been prevented from attending normal births in the hospital.]

~ “the philosophy underlying the campaign to eliminate the midwife created a self-justifying bias towards medical interference in birth. Every time the physician applied forceps or performed a Cesarean delivery, he proved to himself that birth was pathologic and therefore he, the obstetrician, was necessary.” [DeVitt, MD; 1975]

~ “A final underlying issue which contributed to the opposition to the midwife was the remaining 19th century bias of the medical profession, particularly obstetrics and gynecology, against women. the nature of this bias, a contempt for women’s intelligence and physical stamina has been well-documented by Ehrenreich and English (1973), Complaints and Disorders. The vicious tone of the physicians’ articles on “the midwife problem” surely reflect this general contempt for women. This distortion of facts, exemplified in previous quotations, demonstrates that at least the most vocal opponents of the midwife were unable to evaluate her practice objectively. As long as obstetricians sought to gain the esteem of the “medical men”, they could not tolerate competition by the midwife.” [Neal DeVitt, MD; 1975]

~”The passage of midwifery into the mature stream of medical advances has resulted in the parturient women gaining the benefits of (fetal) auscultation, a more complete know of anatomy and asepsis at it developed. Yet, due to the status of women, these advances were kept largely within the circle of male practitioners and thus did not influence the care of the many uncomplicated confinements (managed by midwives) which the physician did not attend.

Conversely, at least in the US, physicians had little contact with midwives and never learned their useful traditions, among them, patience with nature. During the 19th century, obstetricians in England and the US wished to show the scientific nature of their profession. Moreover, in the United States, the dignity of the (obstetrical) profession was thought to be threatened by the practice of midwifery.” Dr. Neal DeVitt, MD, 1975

Dr. Roger Rosenblatt, the Vice-Chairman of the Department of Family Practice Medicine at the University of Washington School of Medicine, was interviewed on April 21st, 1996 on National Public Radio news program “All Things Considered” by Ray Swaraz.

During that interview, Dr. Rosenblatt was very complimentary to the care of midwives, acknowledging that they had much lower rates of Cesareans for low risk mothers (40% less) than care of by physicians. Mr. Swaraz asked Dr. Rosenblatt why the medical profession “frowned on midwives” for all these years. Dr. Rosenblatt’s replied:

” I don’t think its fair to say that they frowned on it. We’re a very heterogeneous bunch in the medical profession. But many have frowned on it because there is a tradition in our country where at some point midwifery was not terribly safe.

We came in with medical obstetrics and we’ve made it an incredibly safe discipline. So I think there is some residue of that. But I think that things have changed now and its time to look again at how we can all work together as a team.”

Need we point out just how inaccurate and unfair this comment is — the notion that “midwifery was not terribly safe“, and that “we came in with medical obstetrics and we’ve made it (midwifery) an incredibly safe discipline“.

Midwifery care for essentially healthy women has always been safer than the medicalized childbirth practices used by MDs. Equally ludicrous is the idea that it was obstetrics that made midwifery safe. Those childbearing women cared for by midwives who have a high-risk pregnancy or develop a complication do indeed benefit from obstetrical care. No one would deny that, or want that to change. But for women who continue to have normal pregnancies and normal labors and births, the physiological care which is usually provided by midwives is the safest and most cost-effective form of maternity care.

Unfortunately the same cannot be said obstetrics. When the interventionist practices of obstetrics are routinely used on healthy women with normal pregnancies, it makes normal childbirth unnecessarily risky. The result of these practices in the US is a tripling of  maternal mortality since 1987 and more than doubling of serious maternal morbidity since 1998.

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