ELIMINATION OF THE MIDWIFE ~ Dr Ziegler, Am Assoc. for Study & Prevention of Infant Mortality ~ 1912

by faithgibson on September 22, 2012

American Association for Study and Prevention of Infant Mortality
Transactions of the Third Annual Meeting
Cleveland, Ohio October, 2-5, 1912
pages 222-237

By CHARLES EDWARD ZIEGLER, A. M., M. D., Professor of 
Obstetrics in the University of Pittsburgh 
Medical Director of the Elizabeth Steel Magee Hospital, 
Pittsburgh, Pennsylvania

It is most gratifying to note the interest which has been awakened in the midwife problem during the past few years. The outlook is hopeful and an attempted early solution of the question may be anticipated. The danger lies in too great haste. Either we are going to settle the matter to our credit and future welfare, or we are going to make a serious and, perhaps, irreparable mistake.

My own feeling is that the great danger lies in the possibility of attempting to educate the midwife and in licensing her to practice midwifery, giving her, therefore, a legal status which later cannot perhaps be altered. If she once becomes a fixed element in our social and economic system, as she now is in the British Isles and on the Continent, we may never be able to get rid of her. I am exactly in agreement with Dr. E. P. Davis, that she is a “menace to the health of the community, an unnecessary evil and a nuisance,” and I am, therefore, unalterably and uncompromisingly opposed to any plan which seeks to give her a permanent place in the practice of medicine. In no other branch of medicine do we permit ignorant, non-medical individuals to give counsel and assistance in medical matters.

Midwifery is the most poorly done of all medical work, not alone because some 50 per cent of all labors are in the hands of midwives, but largely because of the low standards of midwifery existent among physicians and laity alike. And these standards cannot be raised so long as 50 per cent of the cases are in the hands of individuals with as poor preliminary education and as little medical training as have the midwives.

The argument that large numbers of physicians do equally as poor obstetrics as the midwives, is entirely beside the question. We are quite ready to admit this, but to claim that for this reason we must retain the midwife, if we retain the physician, is absurd. Legally the midwife has as yet practically no status, and even if she had, there can be no reason why she should not be subject to the same laws and requirements as those governing all other individuals practicing medicine.

The fact is, as we shall attempt to point out, we can get along very nicely without the midwife, whereas all are agreed that the physician is indispensable. It thus seems that the sensible thing to do is to train the physician until he is capable of doing good obstetrics and then make it financially possible for him to do it, by eliminating the midwife and giving him such other support as may be necessary.

I am opposed to educating and licensing midwives to practice obstetrics in this country for several reasons. First, because I believe it unnecessary, since I am convinced that a plan can be evolved and practically applied which will give to every childbearing woman in the country competent medical attendants. And, second, because I do not believe it possible to train women of the type of even the best of the midwives to practice obstetrics satisfactorily.

In this country, with its great wealth and unlimited resources, it should be, and is, unnecessary that a system should exist and be supported which seeks to give to those unable to pay for competent service, a service which is incompetent and unsafe, and administered by untutored, non-medical individuals. We are passing through a political, social and economic revolution which is certain to result in giving to the worthy poor justice in necessities of life, among which must be included competent medical service, administered by those who are trained in medicine. They will demand it and they are going to get it.

This does not necessarily mean socialism but it does mean social justice. Talcott Williams, in speaking upon “‘Equality of Opportunity” in this country, presents some astonishing facts and figures which show that the trend of modern times is toward “equality of opportunity in all that relates to economic progress.” This fact, as he points out, is apparent in the marvelous growth in savings bank deposits, industrial and regular life insurance and in the increased ownership of houses and lands by the common people, showing that the average citizen is coming nearer and nearer to the place where he is able to secure for himself the things of life which he needs.

If equality of opportunity as regards medical service is ever to come in this country, it cannot come so long as we train one class of practitioners to care for those who can pay and another much inferior class to care for those who cannot. If this be true, then in the name of humanity and of justice let us not give to the midwife a permanent place in the practice of medicine when we know full well that she can never render anything but a service much inferior to that of the trained physicians of the future.

The practice of obstetrics carries with it much more than standing by while the natural forces of labor complete the act as best they may. Obstetrics is an important branch of medicine and to practice it safely and successfully implies a knowledge of general medicine, as well as a knowledge and appreciation of the physiology and pathology—the normal and the abnormal—of the childbearing process. The function of the physician in midwifery cases is to secure for the woman the best possible preparation for her labor, to accomplish her delivery safely and to leave her, so far as possible, in good physical condition; to prepare the mother for, and teach her the importance of nursing her baby and to do everything that is possible to bring this about. A careful physical examination of the patient in each case, a thorough knowledge of her pelvis and a careful study of her previous labors may be indispensable to the successful conduct of her approaching confinement.

It will, perhaps, never be known how many thousands of babies are sacrificed annually at birth because nothing is known of certain deformities and abnormalities until labor is well advanced. Every intelligent physician knows how important is the routine examination of the urine during pregnancy, and yet, in more than 50 per cent of all the labors occurring in the country the urine is never examined until, perhaps, the woman is in convulsions.

Then, too, think of the thousands of women who are annually invalided as the result of unrepaired injuries to the birth canal and from infection, to say nothing of the many who lose their lives. Those familiar with the subject believe that this appalling condition of affairs can be very largely prevented by providing skilled medical attention before, during and after childbirth. This means that pregnancy in each case must be carefully supervised, labor scientifically conducted and the mother and baby left, so far as possible, in good physical condition, which cannot be accomplished by untrained, non-medical individuals as are the midwives.

Another very pertinent objection to the midwife is that she has charge of 50 per cent of all the obstetrical material 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. The whole country is indebted to Dr. J. Whitridge Williams for his studies on “Medical Education and the Midwife Problem in the United States.” He has done a great and lasting service in laying bare the facts in regard to the teaching and practice of obstetrics in this country.

On the other hand, Dr. Jacobi in his inaugural address, at the meeting of the American Medical Association at Atlantic City in June of this year, has taken in my opinion a decidedly backward step as regards both the teaching and practice of obstetrics. His recommendation that 200 schools for midwives be established in the United States is as impractical as it would be impossible of accomplishment. According to Williams, but a single medical school in the country has adequate facilities for teaching obstetrics properly to medical students.

A marvelous thing will have been accomplished if, during the next fifteen or twenty years, thirty institutions similar to the Sloane Hospital, in New York City, are established to meet the requirements of the thirty-one medical schools needed in this country according to Flexner. To accomplish this would require the expenditure of some thirty millions of dollars and an annual budget of more than three millions of dollars to maintain them.

So much is needed before we can hope to give to the students graduating from our medical schools adequate training in obstetrics, and before we can hope to compete with the German medical schools. If then, in addition, an attempt be made to establish the 200 schools recommended by Jacobi or 170 additional ones, using the university schools also to train midwives as in Germany, some idea may be gained of the utter foolishness of such a recommendation.

It is, at present, impossible to secure cases sufficient for the proper training of physicians in obstetrics, since 75 per cent of the material (i.e., mfry teaching cases) otherwise available for clinical purposes is utilized in providing a livelihood for midwives. If schools for midwives were established in all the larger cities of the country, a large number of additional cases would become necessary for training the midwives, and we should soon find ourselves in the anomalous position of favoring the elimination of physicians from the practice of obstetrics, by still further depriving them of clinical material for their training, in order to provide trained midwives to supplant them.

If, moreover, the money which would be necessary for establishing and maintaining 200 schools for midwives, together with what would be necessary to supervise the midwives properly in their practice afterwards, were used to pay physicians and nurses to care for the midwife cases, sufficient money would be available, to say nothing of the five million dollars which it is estimated is collected annually by midwives in this country and which should be paid to physicians and nurses for doing the work properly.

The question in my mind is not “what shall we do with the midwife?” We are totally indifferent as to what becomes of her, as compared with the very vitally important question of how we shall provide competent medical service for the hundreds of thousands of the very best of our women while they are fulfilling the sacred obligations of maternity. And in this we include all classes, for we realize that obstetrics is frequently as poorly done among those who are able to pay for competent services as among the poor, who are dependent upon midwives and upon public charity. The answer is to be found in providing proper training and adequate compensation for physicians and nurses, who alone should do the work.

It is generally recognized that obstetrical teaching in this country is woefully deficient. There has been a dearth of great obstetrical teachers with proper ideals and motives, but the deficiency in obstetrical institutions and in obstetrical material available for teaching purposes has been even greater. It is today absolutely impossible to provide material (i.e., teaching cases) enough to give to medical students before graduation anything more than the merest smattering in practical obstetrics.

So far as I have been able to learn, in all but a few medical schools in this country 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 twenty 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 to a great nation, which in other branches of medicine holds high rank. 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.

On the other hand, it is equally plain that every woman has a right as a citizen and as a mother to such care during and following childbirth as shall preserve her life and health, and those also of her children. It is not difficult to prove that this cannot be accomplished by midwives, but that it can be and is being done by students of medicine under careful supervision, and by recent graduates in medicine who have been trained in well-equipped and properly conducted maternity hospitals. In the Boston Lying-in Dispensary, for example, some 2,000 consecutive cases of labor have been conducted by medical students without a single maternal death, and similar records are to be found all over the country where maternity dispensaries exist.

I believe that the midwife should be eliminated as rapidly as possible, but I do not believe that this can be accomplished at once, nor perhaps even very rapidly. Legislation will not eliminate the midwife unless hand in hand with such legislation provision is made to take her place. While a substitute is being provided she must be supervised in her work. She should, however, not be given a license but should be given a certificate, to be renewed from time to time or cancelled as deemed advisable under the circumstances. Licensing her will not add to her knowledge, and will not make her more efficient but will place upon the state permanent responsibility for her work. No attempt should be made to establish schools for midwives, since, in my opinion, they are to be endured in ever-decreasing numbers while substitutes are being created to displace them.

Please continue to Part 2 –    Dysfunctional nature of welfare for medically indigent maternity patients