V. OPEM -> Legal, Legislative & PR Campaigns to Abolish the Independent Practice of Midwives
V. Strategies to Abolish the Independent Practice of Midwives
The strategy to abolish the profession of midwifery (as practiced by midwives) was multifaceted and included a legal, legislative and public education approach described as “elevating the public conscience”.
A. Propaganda
Medical propaganda centered around the false idea that physician-attended deliveries were safer than giving birth with a skilled midwife. This was not true but the statistical information to refute it was not generally available to the lay public. This propaganda campaign misrepresented the dangers of childbirth and inflated the abilities of medically-based care to eliminate them, while denigrating midwives. In the following quote Dr. DeLee answers the question of how this campaign to “elevate the public conscience” was to be carried out and what exactly the goal of it was to be:
~ “How can this be done? Let us begin with the Women’s Clubs in the United States. Let us tell them of the facts we have learned here today. The Woman’s Clubs in the US are an enormous power, and they are growing more powerful in the civil and social betterment of this country. If we can disseminate among the women of our land the facts regarding obstetrics, there will rise an undeniable clamor for good obstetrics. The public will be forced to furnish the materials, and the patients for the proper instruction of the doctors. They will build maternity hospitals the equal, if not the superior of any surgical hospital.” [1911-B; DeLeeMD]
~ “When public opinion has thus been raised and educated regarding obstetrics, the midwife question will solve itself. With an enlightened knowledge of the importance of obstetrical art, its high ideals, the midwife will disappear, she will have become intolerable and impossible.” [1911-B; DeLeeMD]
Many physicians of the day insisted that midwives were ignorant, dirty and dangerous. The fact that midwives of whatever educational background still had better statistics than physicians only served to infuriate the medical establishment. In truth, a significant number of midwives (40-60% in cities on the eastern seaboard) had been formally educated in reputable European schools of midwifery. These highly-regarded training programs required midwifery students to manage a minimum of 20 deliveries under the watchful supervision of their instructors. There was also a school of midwifery started in NYC at Bellevue Hospital in 1911.
~ “New York City is entitled to the honor of having established the first School for Midwives in the United States under municipal control.”[1911-G] ……
~ “Each midwife must witness or assist in at least 80 deliveries and in addition, deliver a minimum of 20 cases. When this course is completed, a practical and oral examination is given by a visiting obstetrician and if the candidate successfully passes these a diploma is granted.” [1915-A; EdgarMD p. 98]
At this same time, medical students were only required to observe 6 deliveries and often graduated from medical school with virtually no clinical experience. The common complaint by public health officials was that newly graduated physicians offered maternity care without sufficient clinical training, routinely attempted to hastened birth through the injudicious use of drugs and surgical instruments and frequently did not follow public health regulations
In contrast, health officials and other physicians observed that midwives as a group were co-operative in upgrading their skills, followed the directives of public health officials, and had better compliance with laws requiring treatment of newborn eyes and filling of birth certificates than physicians. While it was true of a minority of midwives were untrained and or unskilled, whatever real or imagined deficiency in midwifery education and practice that may have existed during this era, the obvious ethical response would have been to support the establishment of midwifery training programs and regulation of practicing midwives.
B. A Few Good Men and Women — Physicians who knew better
Obviously not all physicians of the day were fooled by these political motives masquerading as a high ideals. While medical politicians promoted massive amounts of misinformation, a small number of midwife-friendly physicians and public health officials who knew first-hand of the excellent success of responsible midwives were vocal in their support of midwives.
~ “The practice of midwifery dates back to the beginning of human life in this world. At this supreme moment of motherhood it is probable that some assistance has always been required and given. Its history runs parallel with the history of the people, and its functions antedate any record we have of medicine as an applied process. To deny its right to exist as a calling is to take issue with the eternal verities of life. The only points upon which we may argue are the training required for its safe and lawful practice, and the essential fitness of those who follow this calling requisite for the safeguarding of the mother and child.” [1911-G; BakerMD, p. 232]
It is thanks to the honesty of these physicians and their concern for childbearing women and babies that we have the documents and statistical records which expose these institutionalized prejudices against midwives. Many of these midwife-friendly physicians managed midwifery training programs or were public health officers. Their well-documented criticisms were recorded in medical journals of the day, complete with tables of compelling statistics clearly demonstrating the scientific basis of their observations. Unfortunately, this crucial information was uniformly ignored by medical politicians.
In 1915 Dr. P.W. van Peyma, Buffalo, NY, 40 years of experience working with midwives and was a member of the Board of Examiners in Midwifery for 25 years stated that:
~ “The essential difference between a midwife and a physician is that (physicians) are free to hasten delivery by means of forceps, version, etc. This, in my experience, results in more serious consequences than any shortcomings of midwives. …Time is an element of first importance in labor, and the midwife is more inclined to give this than is the average … physician. … The present wave of operative interference is disastrous. … The situation would not be improved by turning (the clients of midwives) into the hands of such medical men ….”.
~ “Obstetric training in the medical colleges is recognized as inadequate, [yet] there is no voice raised to eliminate the doctor from the practice of midwifery. Dr. Hirst is at present circularizing the State Board of Health to establish a standard for obstetrical experience for (physician) candidates for licensure, and … he suggests the personal delivery of 6 women. In NYC, the midwife is required to have the personal care of 20 women before a permit is granted to her.
~ “The irregular practitioner of medicine is still permitted to be an obstetrician with an experience that is inferior to that possessed by more than half of the midwives. Let us be fair to the midwife, I say, and if she is below the ideal we have for her, though we have never crystallized that ideal into law, let us give her the opportunity to rise and educate herself under proper supervision.” [1911-G; BakerMD, p. 224]
~ Dr. Ira S. Wile, New York City: “But it is manifestly unfair to criticize the lack of an educational standard which has never been established. When nurses were of the Sairey Gamp type, elimination was not the cure. When apprenticeship was the open sesame to the practice of medicine …elimination was not the cure. Education, training, regulation and control solved these problems just as they will solve the midwife problem. Establish an educational standard, provide sufficient facilities for giving the adequate training, secure the legislation essential to provide the supervision and control and then raise the standard of the midwife so that no further fault may be found. Let us to fair to the midwives and their patients. Let there be an evolution of this class of public servant and not a hasty attempt to check their possible development.” [1911-G; BakerMD, p. 244] {*}
C. Domiciliary or “Outdoor Services” — a normal part of hospital services
During this same period of time, domiciliary or home-based birth services were a normal part of the care provided by hospitals. Domiciliary birth services were not seen as a competition with hospital-based services but rather an extension of care and merely another way that the community could be served by the hospital. This was referred to as their “outdoor service” and described a system in which birth services were provided by a doctor (often an intern or resident) and a nurse who were sent to the home at the mother’s request. It was remarkable for the lower number of complications, especially puerperal sepsis, and the lack of animosity or prejudice against it by the medical community. The outcome statistics from these “outdoor services” were described as the goal or standards to which the hospital “indoor” (in house) service should aspire.
~ “It is in the outdoor (domiciliary) service especially that we are able to appreciate the approach to the irreducible minimum {of mortality} to be obtained in private practice and where the figures are not distorted by the inclusion of the emergency failure of others.” [1917-A; HarrarMD]
~ “From the organization of the service of the Lying-In Hospital in 1890 until July, 1917, the institution has cared for, in the wards and in the homes of the patients, 115,439 women. Of these … 37,483 were parturient and recent admissions to the wards, and 70,743 were labors conducted in the tenements.” [1917-A; HarrarMD]
~ “For purposes of study it is necessary to divide the mortalities in to groups. In the outdoor service, in 69,081 actual confinements, 218 women died. …. This represents one death in every 317 women confined, or 0.31 per cent mortality. …. On the indoor service, of 23,130 regular applicants confined, 109 died. This is one death in every 212 women confined, or 0.47 percent..”[1917-A; HarrarMD] {*}
Unfortunately, as indigent women were brought into the system as teaching cases (receiving free care) it was discovered that they were willing to pay a small sum for their 2 week stay ($1.28) and that even that small amount represented a profit to the hospital. By the early 1920s, maternity patients were beginning to be viewed as not only as valuable “clinical material” for medical education but also as a source of profit to the hospital. Contemporary obstetricians, who know nothing of this era of hospital-organized outdoor (or domiciliary) services, are quite vocal in expressing the opinion that homebirth is risky (“the earliest form of child abuse”). This prejudice is no surprise when coming from people with no knowledge of this historical precedent and no contemporary experience with home-based birth care as provided by skilled midwives in conjunction with easy access to good medical consultation and hospital backup.
~ “The hospital is to care for all who, for one reason or another, cannot secure proper attention at home and the dispensary for those are delivered at home. In the majority of them, her presence in the home is necessary to order and discipline. Then too, the cost of caring for patients in hospital is much greater than in their own homes.” [1912-B, p.231] {*}
~ “The Boston Lying-In Hospital Out-patient department (domiciliary service) cared for 2,007 cases with no deaths, the dangerous cases being sent to the hospital, where all recovered.” [1911-D, p 216]
~ “But another encouraging and very practical feature has been that these 2,007 patients voluntarily contributed to the support of the hospital the some of $2,571 or, on the average, $1.28 contribute by each patient and the total expenses of the out-patient department were $1,763, leaving a net gain of $807″. [1911-C, p. 211]
D. Chloroform & forceps — promoted by doctors as “A Mother’s Best Friend”
The campaign against care as provided by midwives also included the idea that chloroform and the routine use of forceps were an important “improvement” in maternity care and that it was unethical to deny such “advantages” to the “disadvantaged” clients of midwives [DeLee, 1915].
~ “If argument were needed to prove obstetrics a branch of surgery the statistics of the NY Lying-In Hospital for 1909-1910 might be used. Dr. McPherson reports 5,073 patients cared for, of whom 1,037 are classified as “operative”, that is more than 20 % or one in every 5.” [1911-D, p 214] {*}
~ “But all these arguments are unnecessary and insult one’s intelligence. I have visited many European clinics and I am convinced that the reason they are so far behind ours in their obstetric technique is because of the presence of the midwife and the low ideals she establishes” {i.e., eschewing the routine use of interventions such as chloroform, episiotomy and forceps}. [1915-C; DeLeeMD]
The status of women at this time was very low and the common perception was that the practice of midwives, (by mere “women”) reflected negatively on physicians. The theory was that if a mere woman, not formally educated in medicine, could deliver babies, then childbirth managed by doctors was not a really “respectable” practice of medicine nor worthy of a higher fee than the customary pittance paid to the midwife (two and half to five dollars).
~ “Obstetrics is held in disdain by the profession and the public.. The public reason correctly. If an uneducated women of the lowest class may practice obstetrics, is instructed by doctors and licensed by the State, (birth attendance) certainly must require very little knowledge and skill —surely it cannot belong the science and art of medicine.” [DeLee, MD 1915]
E. “First, Catch Your rabbit” –legal and legislative strategies to suppress and abolish midwives
The legal and legislative aspects of the campaign included a strategy to make the practice of midwives illegal where every possible.
~ “In states where the midwife is practically unknown, it should be seen to that the Medical Practice Law excludes the possibility of midwives practicing within the limits of the state. In states where the midwives are not forbidden by law and are numerous, a well organized license and regulation system should control those in practice. Outline for them the minimum standard for their cases and enforce at least this standard by taking away the licenses of those who violate the law. Renew the old licenses every year and issue NO NEW ONES. Thus the midwives will gradually be excluded from practice by their own incompetence and by the lapse of time.” [1911-C, p. 209]
~ “…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] {*}
Many medical politicians reported that it was hard to get a judge and jury to take the “unlicensed” practice of midwifery as a sufficiently serious offense, so that charging midwives with the “illegal practice of medicine (instead of the unlicensed practice of midwifery) was more successful at getting convictions.
~ “Moreover, it is a hard matter to obtain the proper evidence to convict such persons, and we have never had an instance in a year and 4 months of (the) execution of the Midwifery Law of an accusation being brought against midwives by either a patient or a physician, (except a health officer).” [1911-F, p. 22
In areas where midwives has already achieved legal status, the tactic was to suppress and eventually abolish them by ever-escalating educational requirements and regulatory controls.
~ “I believe that the midwife should be eliminated as rapidly as possible. She should, however, not be given a license but should be given a certificate, to be renewed from time to time or canceled 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.” [1912-B, p.227]
~ “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] {*}
~ “Have the license to practice be an annual affair based on the record for the previous years. Then by gradually raising the standard and providing dispensary care (free clinics and home delivery by medical students), .. the problem in a few years would simply (solve) itself.” [1911-C, p. 210]
Furthermore, these strategies included a policy preventing the establishment of midwifery training programs and the licensing of midwives.
~ “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]
~ ” 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]
~ “…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 ]
~ “Do ophthalmologists favor a school for the instruction of optometrists…? Why not train the chiropractor and Christian Scientists also?” [1915-C; DeLeeMD p. 115]
This was to keep midwives from acquiring the legal protection of an independent profession which would have established normal maternity care as the legal domain of midwives (i.e. requiring physicians to be trained in the principles of midwifery in order to provide normal pregnancy care to healthy women). Many “medical men” of the day complained that licensure “would give the midwife to much dignity and importance” (Mabbott, 1907).
In 1923, Baily compared the record of student midwives at the Bellevue Hospital School of Midwifery to that of physicians:
~ “Their handling of normal cases of labor has been conducted with fewer deaths of the mothers from sepsis and with as low a number of stillbirths and eye infections of the babies as the cases handled by the medical profession.”
By keeping midwives from the “discipline of rigorous institutional training which led to the prestige of professionalism, they consequently kept from the midwife the ability to assume the aura of medical progress. … not only did physicians attempt to woo her patients away by withholding from the midwife the status of a trained professional” [Chaplin, MD; 1919] but they sought subsidies to compete with her ecumenically as well. Physicians, but never midwives, were supported by obstetrical charities to who compensated then for providing maternity services to the poor.
Midwifery licensure would also have required physicians to respond to requests from midwives for medical assistance in complicated cases and established legal penalties for those doctors who did not comply.
~ concerning management of complicated midwifery cases by German midwives — “the midwife … must notify a physician in writing …or communicate personally over the telephone. And the physician must in such case respond at once, unless actually engaged on a case that requires his immediate attention, when he must so communicate to the midwife or messenger. Should the midwife or the physician fail to follow these laws, (they both) are subject to punishment.” [1911-C, p. 203] {*}
This was one aspect that particularly irked the medical community — the very idea of “medical men” ( as doctors of the day preferred to be called) being “bossed” around by a midwife at a time when their own wives did not have the authority to demand their co-operation!
~… “(S)upervising the midwife,… and not only that but a medical profession forced by law to respond to the call of the midwife in trouble.”[1911-C, p.208]
One must remember the state of gender relationships in the late 1800 and early 1900s which was the social foundation of male sovereignty used to configure an equally sovereign practice of medicine which remains unchallenged and unchanged today.
An added complexity in the physician-midwife relationship was the recognition by the medical community that many doctors did not effectively treat a patient referred to them by midwives because it was so easy to explain a bad outcome by simply saying that the midwife should have called him sooner.
~ “Then too the physician when called to such a case is far from being as careful as if it had been his case from the beginning, for it is so easy to say that had he been called earlier ‘all would have been well’”. [1911-C, p. 205]
F. Removing the word “Midwife” from the Birth Certificate Law
~ California Health and Safety statutes, regarding the mandatory registration of birth; 1915, Chapter 548, page 723: “In case no physician was in attendance [at the birth] it shall be the duty of the midwife or person acting as midwife to file such certificate“
Last but certainly not least in the legislative weapons of the medical establishment was a strategy to remove the word “midwife” from the birth registration statutes. This meant that henceforth, only physicians could register the birth. This was very good for the statistics of the medical community, as there was no longer any category of “midwife-attend” birth to contrast unfavorably with physician outcomes. Conveniently, it also gave the medical board “proof”, in the form of a signed birth certificate, to use in disciplinary actions against doctors who “cooperated” with midwives.
~ “What we must first do is arouse public sentiment and first of all we must have the enthusiastic support and united action of the medical fraternity…. We feel that the most important change should be in the laws governing the registration of births. The word “midwife” as it occurs, should be at once erased from the statute books. …
We believe it to be the duty and privilege of the medical profession of American 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.” Boston Medical and Surgical Journal, Feb. 23, 1911, page 261 {*}
This strategy is alive and well today in California. Because the 1957 California birth registration statute, in which the word ‘midwife’ is conspicuously absent (conspicuous because state certified midwives were practicing at the time), all domiciliary births attended by nurse and direct-entry midwives are classified as ‘unattended’ home births.
~ “For live births that occur outside of a hospital, the physician in attendance at the birth, or in the absence of a physician, either one of the parents shall be responsible for entering the information on the certificate, securing the required signatures, and for registering the certificate with the local registrar.” Cal H&S Code 10102
The California Department of Vital Statistics thus far declined to acknowledge the category of “midwife-attended” birth (citing the absence of the word “midwife” in the law) which means that the statistics for birth with a skilled attendant are lumped together with those with unattended births. These inaccurate statistics affect maternity policy within the state and the computerized records from California then sent into the national data bank, further muddying the waters.
G. Low cost substitutes financed by the Rockefeller and Carnegie foundations
According to the New York Journal of Medicine (1915, p. 300) —
~ “The development of substitute agencies is the most essential factor in the elimination of the midwife, and the element of competition [free services] will do more to eliminate their practice than anything else.”
In addition to other strategies, the successful abolition of midwives also depended on developing a low cost substitute for the integrated care of midwives. This was achieved by organizing obstetrical charities, financed largely by the Rockefeller and Carnegie foundations, to provide free antepartal clinics during pregnancy, free hospitalization in charity wards for birth and free obstetrical care by medical students as a part of their formal education.
~”(H)owever, to entirely eliminate the midwife, it will be necessary for the government to substitute some cheap service at the time of birth. A women will employ a midwife who will render such services as she can at the time of birth and attend to the women for a certain period after birth, giving many ministrations to the mother and child that no doctor will undertake to furnish. The only way to eliminate the midwife is to furnish some proficient and at least equally cheap service.” [1915-H]
Many doctors of the era insisted that this system of free care in exchange for becoming a “teaching case” should be paid for by government out of tax revenues, in recognition of the “great benefit” derived from medical education by the public. By the 1960s this historical marriage of the medically indigent with medical education had been transformed into the federal Medicaid program.
~ “For many physicians, especially some noted obstetricians, there is no midwife problem; they have long since settled the question by vehement condemnation of the midwife and the recommendation that all who engage midwives from tradition or economic necessity should be delivered in finely appointed hospitals at public expense.” [1917-B; Levy, MD]
H. Dividing up the Profession of Midwifery Between Physicians and Nurses
~ “Of the 3 professions—namely, the physician, the trained nurse and the midwife, there should be no attempt to perpetuate the last named (midwife), as a separate profession. The midwife should never be regarded as a practitioner, since her only legitimate functions are those of a nurse, plus the attendance on normal deliveries when necessary.” [1915-A; EdgarMD p. 104]
Another important historical strategy was to eliminate independent (or non-nurse) midwives from the profession of midwifery by dividing midwifery practice up between physicians and nurses, much like a piece of whole cloth taken from midwives and torn into two unequal pieces. The big piece went to doctors (the independent and high-paying end) and the smaller, subservient (and low paying) one went to nurses. The bottom line was the “necessity” (as seen from the physicians perspective) to maximize their per unit/patient profit by minimizing their per unit/patient time. This was to be achieved by having nurses do most everything but catch the baby (and collect a representational share of the fee).
~ “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, and midwives.” [1922-A; ZieglerMD, p. 412]
~ “The nurses should be trained to do all the antepartum and postpartum work, from both the doctors’ and nurses’ standpoint, with the doctors always available as consultants when things go wrong; and the midwives should be trained to do the work of the so called “practical nurses,” acting as assistants to the regular nurses and under their immediate direction and supervision, and to act as assistant- attendants upon women in labor—conducting the labor during the waiting period or until the doctor arrives, and assisting him during the delivery.” [1922-A; ZieglerMD]
~ “In this plan the work of the doctors would be limited to the delivery of patients [i.e., birth as a surgical procedure performed by the physician], to consultants with the nurses, and to the making of complete physical and obstetrical examinations … Under this arrangements, the doctors would have to work together in a cooperative association with an equitable distribution of the work and earnings.” [1922-A; ZieglerMD, p. 413]
part A –> http://collegeofmidwives.org/collegeofmidwives.org/safety_issues01/rosenbl3.htm
part b –> http://collegeofmidwives.org/collegeofmidwives.org/safety_issues01/rosenb4.htm
