Midwifery vs. Midwives: what doctors called “the midwife problem”

by faithgibson on November 25, 2012

OVERVIEW: The following historical material refers to”the elimination of the midwife” and “the midwife problem”  and also to the elimination of midwifery as a professional discipline. Its important to note that these are two very different topics and their impact on the development of maternity care in the United States was very different. 

The historical practice of “midwifery” refers to the art and science of normal maternity care for healthy women — physiologically-based management — as provided by both midwives and physicians.

Until late in the 20th century, midwifery has been the normal system for providing maternity care in both developed and developing countries. Routine midwifery care is remarkably effective in reducing complication and preventing maternal-infant deaths compared to outcomes in childbearing women who had no access either midwifery or medical care  — that is, no regular prenatal care, and/or no trained attendant present during labor and birth and either had no access to emergency services (often the case in poor developing countries) or they or their families refused to use such services.

A review of the scientific literature identifies the single most critical element of safe childbirth as access to maternity care. It does not matter if that care is provided by a physician or a professional midwife. The best outcomes for healthy mothers and babies are consistently associated with three healthcare-related circumstances that are equally advantageous to women living in high-income industrialized countries and low-income developing countries.

(a) Antenatal care with risk-screening & referral for medical evaluation or treatment as indicated
(b) Birth attendant (s) skilled and experienced in physiological management who remain present or immediately available at the mother’s discretion during active labor, and fully present during birth and postpartum-neonatal period
(c) Access and appropriate use of hospital-based obstetrical services for complications or if medical care is requested by the mother

 This integrated system presupposes two things:

(1) universal access to a functional healthcare system based on modern biological science

(2) that provides affordable medical services — both routine and emergent — to women and children over the entire course of their lifetime.

No form of maternity care or obstetrical intervention can provide the characteristics of good health to women who suffer from chronic disease or begin pregnancy with a serious illness that could have been prevented by timely access to appropriate medical treatment.

One example of an integrated, government-supported system is the Swedish maternity care system.of maternity care primarily provided by midwives with was  It depended on formally trained and state-regulated midwives to attend normal labors and birth, in conjunction with general practice physician who were called on when medical or surgical intervention was needed.

Sweden’s midwifery system was further improved and modernized in 1881 by passage of a national law requiring all birth attendants to strictly adhere to the principles of asepsis (hand-washing, clean supplies and sterilization of equipment). This law specifically applied to both physicians and midwives. By the beginning of the 20th century, the maternal mortality rate in Sweden was one of the lowest in the world — 230 per 100,000 live births. [ref #1] On average, it was 3 times safer to give birth in Sweden than in the US in 1900.  According to this informative source [ref #1]:

“Maternal mortality in Sweden declined from 900 per 100, 000 live births, to 230 per 100, 000 [between] 1751 to 1900. From 1900 through 1904, Sweden had an annual maternal mortality of 230 per 100, 000 live births,while the rate for England and Wales was 440 per 100,000. For the year 1900, the United States reported 520 to 850 maternal deaths per 100,000 live births.”

In sharp contrast to Sweden’s one fatality out of 434 birth, birth in the US in 1900 would result in a maternal death for one out of every 117 to every 192 live births.

Nonetheless, American physicians objected to the nationalized healthcare systems used in many European countries. They also did not want a cooperative practice between professional midwives and physicians forced on them by the government. Instead they saw midwives as interfering with their practice of midwifery as physicians. This is the origin of what they called “the midwife problem” and the basis of an official campaign by the medical profession that began in 1910. Its goal was to bar midwives FROM the practice of midwifery.

Working to abolish the lawful practice of midwives was a direct and purposeful act, while the elimination of midwifery was indirect and accidental. The medical establishment, lead by two particularly influential obstetrical professors, wished to eliminate the maternity care provided  by midwives Drs Joseph DeLee at Northwestern University in Chicago and J. Whitridge Williams at Johns Hopkins did NOT originally intend to impact on  midwifery as a distinct discipline practiced by physicians when providing care to healthy women.

Eliminating midwifery from mainstream healthcare was the unintended consequences of the campaign’s rhetoric, which was  designed to justify their actions against the lawful practice midwives. This strategy intertwined two assertions  — first was the claim that all American midwives were either untrained or inadequately trained, and second, that childbirth itself was an inherently dangerous and pathological process that routinely required  surgical skills, thus could only be performed by an MD.

The medical profession successfully argued that it was impossible for midwives to be adequately trained, since the only ‘appropriate’ level of training required that they go to medical school and become doctors licensed to practice medicine and surgery. That medical schools did not want, and in many cases, would not accept women as medical students was irrelevant.

Once these assertions had been accepted as a rational premise,  childbirth practices veered farther and farther from the core of midwifery — physiological support for the processes of normal biology. This eventually made  the  medical profession a prisoner of its own project, painted into a narrow corner by their insistence that normal birth be universally conducted in a restricted environment under conditions of surgical sterility on women who were unconscious under general anesthesia. Furthermore, it was to be ‘performed’ only by an MD who followed protocols for normal birth that included a series of surgical procedures — episiotomy, the use of outlet forceps, and manual removal of the placenta, followed by suturing of the perineal incision.

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

Under these extremely medicalized circumstances, it was no longer appropriate to call these doctors ‘man-midwives’ or refer to this medical-surgical discipline as “midwifery”. In that moment, the supportive model of maternity care historically known as midwifery ceased to exist. It was instantaneously replaced by obstetrics as a surgical discipline that taught doctors to routinely use invasive medical and surgical interventions during normal birth as a preventative strategy. The medical profession itself enthusiastically embraced all these surgical intervention, and widely embraced interventions that induced or sped up active labor or shorten the pushing stage, such as episiotomy and forceps.

Unfortunately, it took several decades for medical schools to catch up with the many dramatic changes in obstetrical policy and practice. During this long period of inadequately trained doctors (1910 to the early 1930s) maternal mortality in the US rose from a baseline in 1900 of 665:100,000, to a high of 1,200 death per 100,000 in 1925. Out of 2 million live births in 1925, there were 25,000 maternal deaths reported (one out of 80) . [ref #2] It took 30 years for medical schools to improve their educational curriculum and clinical training in order to dependably train its students in the surgical discipline of obstetrics, thus rendering them relatively safe practitioners upon graduation.

However, the maternal mortality rate during this time remained significantly highly than the rest of the developed world. During this pre-antibiotic period, even well-trained MDs practicing in well-staffed hospitals were not enough to make the regular use of these invasive obstetrical practices safe for mothers and babies. It required access to the new category of antibiotic drugs  (sulfa and penicillin) starting in the late 1930s and early 1940s, in combination with safer surgical techniques developed by battlefield medicine during WWII — particularly safer blood transfusions and safer anesthetics — that finally by the mid-1950’s made normal birth as a surgical procedure acceptably safe for mothers. [ref #3]

It would be another two decades before this same level of improved safety would apply to newborns. During the many decades that Twilight Sleep drugs and general anesthesia were a routine part of maternity care, babies in utero were exposed to disproportionately large doses of  drugs and anesthetic agents. The 7-pound baby got the same ratio of narcotic that was being given to its 140 pound mother during labor and the same dose of general anesthesia used for the delivery. As a result, a significant number of newly born babies had a fatal respiratory depression or suffered from permanent neurological disabilities. The work of a woman anesthesiologist — Dr. Virginia Apgar — in the 1950s was crucial to making practices relative to obstetrical drugs and anesthetics substantially safer for unborn and newborn babies. [ 3 ref — ibid above]

By the early 1990s, the practice of giving large doses of  narcotics during labor and general anesthesia for delivery was replaced in the vast majority of American hospitals — those busy enough to pay the salaries of a full-time obstetrical anesthesia staff — with the intrapartum (labor and birth) use of epidural anesthesia. Combined with many life-saving advancements in the care of premature babies and access to high-tech neonatal intensive care units, mortality and morbidity rates for both mothers and babies were vastly improved in comparison to the previous decades.

However, the United States still lags way behind other developed countries. Despite a national Cesarean rate of 32.8 % — a ‘rescue’ operation supposedly done to prevent serious complications — we  still rank behind 50 other countries in maternal mortality and (??) about 30th in perinatal mortality. In California maternal mortality rose from 8 to 14 per 100,000 between 1999 and 2008.

A major contributing factor in the rising maternal death rate are complications from repeat Cesareans.  This reflects a preference by the obstetrical profession for routinely performing repeat Cesareans instead of recommending and supporting a vaginal birth after Cesarean (VBAC).  Often this is a medico-legal issue caused by malpractice insurance premiums that are prohibitively high for physicians and hospitals who want to provide VBAC care. As a result, well over 50% of hospitals in the US have policies that prohibit maternity patients who have had a previous cesarean from laboring and giving birth vaginally.

In post-Cesarean pregnancies, the placenta frequently grows into the scar tissue at the site of previous uterine incision. This drastically increases the instance of placenta previa and those where the placenta adheres to the wall of the uterus after the birth and cannot be delivered as usual. Sometime this low-implanted placenta grows through through the wall of the uterus and attaches its blood supply to other abdominal organs such as the bladder. This is known as ”placenta percreta’. All of these are extreme obstetrical emergencies and many will require an emergency hysterectory at the time of the Cesarean delivery. For women with a placenta precreta that is grown deep into the uterus, death from massive uncontrolable hemorrhage occurs between 7 and 10 % of the time despite being in the best hospital under the care of excellent obstetricians and having received a massive number of blood transfusions.

The number of women with complications from abnormal placentation after a previous Caesarian section has risen precipitously and their deaths are a major factor in the currently rising maternal mortality rate in the United States. [ref #4]

The obstetrical profession generally agrees that 500 Cesareans must be performed (NNT) in order to save the life of one baby. The context for this observation is 500 non-reassuring fetal monitor strips that triggered a decision often described by obstetricians as “when it doubt,cut it out”, alternatively known as “vaginal by-pass surgery”.

What is sad and disturbing about this is the other 499 women and their 499 unborn babies who will all face a dramatically increased risk of life-threatening complication in all their future pregnancies due to the ‘liberal’ (one might say casual) use of Cesarean section.

The Individual Midwife vs.
The Historical Discipline of Midwifery

During the last decades of the 19th century the topic of  ‘midwifery’ presented the medical profession with a confusing public relations dichotomy. Doctors had noted that attending births was the key to building an economically successful medical practice. As a result they had long ago redefined the discipline of midwifery to be an important part of their general practice of medicine. The gratitude of the new mother for being “tenderly and safely” cared for during childbirth was expected to generate loyalty to her doctor, which in turn would create many opportunities to provide other kinds of medical services to her family and nearby neighbors.

Here is how the issue was described by a physician in 1820 in a medical journal:

Women seldom forget a practitioner who has conducted them tenderly and safely through parturition…  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.” [5]

In the comment below, a physician argues against permitting midwives to provide care to childbearing women because doing so would cause doctors to loose social status:

“… 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]

By the beginning of the 20th century the medical profession decided the time was right to fully professionalized midwifery as a form of care provided exclusively by MDs.

As man-midwives, doctors needed to disengage the concept of  ‘midwifery’ from its natural association with women-midwives as birth attendants. This inadvertently created a major dilemma — how to convince the lay public to reject midwives as providers of midwifery care,  while simultaneously promoting midwifery as a medical practice?

By the first decade of the 20th century this issue came to be known internally as “the midwife problem“. This was taken very seriously by the medical profession and triggered a coordinated campaign to permanently remove midwives from the lawful practice of midwifery. [2] The plan began with a group of influential surgeons who officially promoted obstetrics as the modern scientific replacement for what they described as the unscientific, unsafe care of midwives. The second part of the plan was an organized PR campaign that portrayed midwives as old-world relics of a by-gone era that needed to be phase out of “the birth business” as aggressively and rapidly as possible.

A similar quote (1975) from a more modern source (New York Times Magazine) captures both the the dysfunctional historic relationship between midwives and obstetrical medicine and reveals how this prejudice has survived virtually intact through out the 20th century.

“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 attached the problem, women were persuaded to have their babies in hospitals, and to be delivered by physicians…. Today it is rare for a women to die in childbirth and infant mortality is (low)…” [Steinmann, 1975]

It is insightful to note the ‘guilt-by-association’ technique in which the author (erroneously) states as an undisputed fact that midwives in the early 20th century were “largely old-fashioned untrained “grannies“‘. Then without any corroborating data states in the very next sentence, as if this was an obvious ’cause and effect’ relationship, that “Maternal and infant mortality was appallingly high in those days…

The NYT article was correct about the ‘appallingly high’ maternal and infant mortality, but the problem was not the physiological care and supportive services provided to new mothers and babies by these early 20th century midwives. Outspoken physicians of the era, studies published in peer-reviewed journals and state birth records all vigorously dispute these claims that categorically impugn the reputation of midwives, while extolling physicians as paragons of safe practice.

The diagnostic ability of midwives is generally good and in the case of many, remarkable excellent. In this respect, the average midwife is fully the equal of the average physician.[Van Blarcom, MD; 1913]

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]

Of the babies attended by midwives, 25.1 per 1000 … died before the age of one month; of those attended by physicians, 38.2 per 1000 …. died before the age of one month; and of those delivered in hospitals, 57.3 per 1000 died before the age of one month. These figures certainly refute the charge of high mortality among the infants whose mothers are attended by midwives, and instead present the unexpected problem of explaining the fact that the maternal and infant mortality for the cases attended by midwives is lower than those attended by physicians and hospitals.” [1917-B, Levy,MD; p. 44] {emphasis added}

“Clearly the midwife seemed to be the safest birth attendant” [Devitt, MD; 1975]

Reports on the efficacy of care by midwives were yet again confirmed at a White House Conference on ‘Child Health and Protection’ by the Committee on Prenatal and Maternal Care. It’s author, Dr. 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.” (original emphasis)

By 1910 efforts by organized medicine to remove midwives from the practice of midwifery were ramped up to include articles in newspapers and women’s magazines. They quoted nationally-influential physicians who identified  midwives as a dirty, dangerous and downright incompetent lot who were illegally (and poorly!) practicing medicine without a license.  Books and other publications, including a pamphlet promoting prenatal care by the Metropolitan Life Insurance Company, enthusiastically described physician birth-attendants as the clearly superior and scientific choice for modern families and cautioned women not to go to midwives. [6]

“Under no circumstances should a midwife be engaged. Any reputable physician or … intellectual minister will advise that. Let your choice be either the hospital or the home; but always engage a physician, never a midwife.”

[The Expectant Mother ~ The Mother and Her Child, ‘Childbirth’ section, page 8 -William S. & Lena K. Sadler, M.D ~ 1924; emphasis added   

The prejudice against midwives went beyond any rational argument, as revealed in the following list of comments by various physicians.

In 1906 Dr. Gerwin expressed his opinion as:

“the typical, old, gin-fingering, guzzling midwife, … her mouth full of snuff, her fingers full of dirt and her brain full of arrogance and superstition” 

Shortly afterwards (1907) Dr. Mabbott characterized midwives as “un-American“; in 1912 Doctors Emmons and Huntington said they suffered from:

“the overconfidence of half-knowledge, …unprincipled and callous for the welfare of her patients”

Dr. De Lee, who is personally my favorite of these historical obstetricians and truly a kind man, nonetheless wins the ‘snarky award’ by saying:

“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.” [TASPIM- 1915-C; .p. 114]

“Any scheme for improvement in obstetric teaching and practice which does not contemplate the ultimate elimination of the midwife will not succeed. This is not alone because midwives can never be taught to practice obstetrics successfully, but most especially because of the moral effect upon obstetric standards.” [The Teaching of Obstetrics”, American Association of Obstetrics and Gynecologists]

Dr. Williams remarked that:

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

“First, Catch Your Rabbit” ~ midwives as pawns in someone else’s game of charades

Increasingly audacious sentiments were expressed over the ultimate fate of midwives in America as doctors got together at an annual conference of the American Society for the Study and Prevention of Infant Mortality, which met each year from 1910 to 1015. In the committee that met to address the ‘midwife situation’, physicians and nurses (but not midwives) argued about the desirability of formally training and professionally licensing midwives in the US (as done in UK, Holland, France, Italy, Germany, Scandinavia, Switzerland and Japan) versus the a ramped-up campaign to abolish the practice of midwives by making it illegal for them to have anything to do with midwifery.

One of the doctors quoted below saw strict licensing laws as a clever strategy that would enable the medical profession to set a trap that would legally ensnare midwives. Because the letter of these laws could be crafted in a way that would be impossible for midwives to comply with, doctors could see that midwives were one-by-one criminally prosecuted until all the midwives in their jurisdiction were put out of business. He referred to this tactic as “First, catch your rabbit”:

” I am opposed to educating and licensing midwives… I do not believe it possible to train women of the type of even the best of the midwives to practice satisfactorily.” [1912-B, p.223]

“No attempt should be made to establish school for midwives, since, in my opinion, they are to be endured in ever-decreasing numbers while substitutes are being created to displace them.” [1912-B, p.227]

“Do ophthalmologists favor a school for the instruction of optometrists…? Why not train the chiropractor and Christian Scientists also?” [1915-C; DeLeeMD p. 115]

“…the great danger lies in the possibility of attempting to educate the midwife and in licensing her to practice midwifery, giving her …a legal status which cannot …be altered…”[1912-B, p.222 ]

” … it should be seen to that the Medical Practice Law excludes the possibility of midwives practicing within the limits of the state. [1911-C, p. 209]

“It is quite possible by strict educational requirements, by imposing certain qualification as to the experience and training, and in other ways, to restrict the practice of midwifery to such a degree as to amount to practical abolition. Such a method is necessarily more slow than direct abolition. It can be carried out, … according to the forms of law.” [1911-E, p. 225] 

“…the best argument for a state law, namely, because a midwife once convicted of a crime would afterwards be disqualified to practice by reason of said conviction. First catch your rabbit.” [1907, Dr. Mabbott; American Journal of Obstetrics]

Abolitionist doctors also looked ways to displace the low-cost care provided by midwives for poor and immigrant women by providing free ‘dispensary’ (outpatient) services. Charitable contributions were solicited from wealthy individuals and organizations, particularly the Rockefeller and Carnegie family foundations. This paid for the new maternity clinics and the ‘external’ (out-of-hospital) birth services provided by medical students and interns and nurses employed by the hospital.

Other strategies were also developed to gradually put midwives out of business in places where the medical lobby had been unable to make the practice of midwives illegal. However, organized medicine did not always get what it wanted even when they succeeded in outlawing midwives. Many a sheriff was reported to have said that the law, as well as the men who wrote it, was ‘stupid’ and they refused to arrest the midwives in their jurisdiction.

These events took place between 1900 and 1920, a time when women did not yet have the right to vote. Midwives of the day were often immigrants trained in European midwifery schools who were not literate in English. No records or reports exist of any organized or effective push-back from the community of midwives. With the lone exception of a few sympathetic sheriffs who refused to serve a warrant, this politically asymmetrical situation reflected gender politics of the time. White, male, upper-class physicians were greatly advantaged, while midwives had neither the social connections nor economic resources to mount an aggressive political rebuttal.

It also speaks of the widespread enthusiasm for the new biological sciences and the uncritical acceptance of notion that all human problems would be quickly and easily solved by these newer, supposedly more ‘scientific’ methods. In a single decade (1910-1920), births registered by midwives fell from approximately 50% to 13%. In the northeast corridor (backyard to the medical schools at Harvard and Johns Hopkins) the lawful practice of midwives was virtually eliminated, while in the South black ‘granny’ midwives provided care to poor and racially segregated populations that could not afford a doctor or were not allowed to received care in white-only hospitals.

II. Medicalized midwifery taken over by the new surgical speciality of obstetrics

A central tenet of organized medicine’s plan was the idea that ‘modern’ obstetrics was no longer a general practice of medicine but was instead  a new surgical discipline.  it identified childbirth in all its forms and circumstances its proper scope of practice of what it called ‘the new obstetrics’, This included healthy women with normal pregnancies, as well those suffering from the complications of pregnancy and childbirth. The issue here was surgical training, something that was only available to doctors. For example, a Dr. Holms in 1920 stated that:

“Only the properly trained physician who has acquired surgical techniques with specialty training in obstetric physiology and pathology is competent to circumvent the many ills of childbirth.”

Read more …..

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References:

1. The Decline in Maternal Mortality in Sweden: The Role of Community Midwifery

Ulf Högberg, MD, PhD; August 2004, Vol 94, No. 8 | American Journal of Public Health 1312-1320

2004 American Public Health Association PUBLIC HEALTH THEN AND NOW

The author is with Obstetrics & Gynecology, Department of Clinical Science, and Epidemiology, Department of Public Health and Clinical Medicine, University of Umeå, Umeå, Sweden.

2: Excerpts from the transactions of the American Society for the Study & Prevention of Infant Mortality — 1910-1915 – Official Plan to Eliminate the Midwife; College of Midwives.org

3. THE SCORE: How childbirth went Industrial  by Atul Gawande, MD; published in October 9, 2006 edition of the New Yorker

4. OBGYN.net ~ By Jonathan Leaf | November 26, 2012 @ http://hcp.obgyn.net/pregnancy-and-birth/content/article/1760982/2116593?cid=newsletter

5.“Remarks on the Employment of Females as Practitioners in Midwifery” Published by Cummings and Hilliard – Boston, 1820

Pertinent excerpts from a pamphlet by a physician originally published more than 150 years ago.  It attests to the common belief by medical professionals at the time of its publication (1820) concerning midwives and the desirability of usurping midwives from the midwifery so that it would become an MD-only discipline.  The rejection of women as “practitioners” was based on a series of factual errors, misunderstandings and self-serving ideas.

PDF of entire book:

http://collections.nlm.nih.gov/muradora/objectView!getDataStreamContent.action?pid=nlm:nlmuid-2545065R-bk&dsid=PDF&mimeType=application/pdf

6:  The Expectant Mother ~ The Mother and Her Child ~
1924 
William S. & Lena K. Sadler, M.D

This was an extensive, 4-part article written for lay public & published in Women’s magazines that stated:

Under no circumstances should a midwife be engaged. Any reputable physician or … intellectual minister will advise that. Let your choice be either the hospital or the home; but always engage a physician, never a midwife.” –> Part 2 – Childbirth section, page 8 – emphasis added

(1) Pregnancy including advice to never use the services of a midwife
(2) Childbirth includes Twilight Sleep, other anesthetics
(3) Newborn  care and development
(4) Infant Feeding ~ Breast and Bottle

7: The Transactions of the Edinburgh Obstetrical Society Volume VI Session 1880-1881
http://books.google.com/books?id=gZ8EAAAAQAAJ