Historical and contemporary comments by physicians about midwives ~ 1820 to 2014

7348388772_820325c5d1_n-223x300

The following historical and contemporary quotes by were made by doctors about midwives over the course of the last 2 centuries on a topic referred they referred to as “the midwife problem”.

Historically, this type of “problem” — the Jewish problem, the immigration problem, the ‘colored’ problem — always reflects a prejudice against a distinct group and all its members.  Today, we describe getting together to get rid of a population as either a ‘hate crime’ or, depending on the scale, genocide.

As you read these historical comments spanning more than 200 years, you can’t help but realize that the goal of the obstetrical profession, with the help of organized medicine (i.e. the AMA) was the eradication (i.e. genocide) of the midwifery profession, accompanied by hate crimes against individual midwives. But the really unforgivable ‘crime’ was what influential leaders in American obstetrics did when they branded normal childbirth as an intrinsically pathological aspect of human biology.

This was accompanied by a well-financed, well-organized social and economic campaign to totally eliminate even the idea that of “normal” labor and birth, substituting instead the idea that labor was a pending medical emergency that required the use of many drugs and the birth of the baby was only safe when conducted as a surgical procedure ‘performed’ by a physician-surgeon after the mother had been rendered unconscious by general anesthesia.

The Hundreds Years War on Normal Childbirth

Within the medical community there were — and continue to be — a very wide difference of opinion on the value (vs. danger) of physiologic management of normal childbirth and proper role for midwives (as independent practitioners) who provide physiologic childbirth services to healthy women with normal pregnancies.

While physicians fiercely debated the ‘midwife problem’ over the last 2 centuries, midwives and the childbearing women who used their services, were unfortunately not invited to participate in these important discussions.

I hope these dramatic, conflicting, and often disparaging comments among members of the medical profession will provide a helpful perspective to better understand the political tension and on-going controversies between medicine and midwifery in contemporary times.

I describe this historical topic as the last and most important UNTOLD story of the 20th century.

For many centuries the controversy within the medical profession over what they called “female practitioners of midwifery” simmered on the backburner. It finally burst into flames in the US in the early 20th century and has been going strong ever since.

This amazingly upsetting and frustrating story is still a very long way from being over. 

JAshford Egyptian tree mom MW

Midwife assisting a laboring woman in ancient Egypt

Agnodice_engraving

A modern engraving of “Agnodice“, a midwife and obstetrician in Ancient Greece, who according to legend disguised herself as a man in order to practice as a doctor

JAshford African Stand 3some

A native American couple, with husband holding his wife steady in an upright position as she pushes and the midwife receives the baby

0
** Editor’s Note: Important vocabulary distinction btw the words “midwifery” and “midwife“; also a definition of midwifery and obstetrics as a historical and contemporary discipline:
0
For doctors, the historical topic of midwifery was politically and practically very different from the discussions of individual midwives as ‘female practitioners of midwifery’. During the 19th and early 20th century, doctors were NOT trying to eliminate midwifery, per se. In fact, a physician who attended births was practicing the discipline of midwifery and were actually known as “man-midwives“.
0
However, many doctors were interested in eliminating midwives from the practice of midwifery. From their perspective, care provided by midwives was an illegitimate encroachment on the entitlement of physicians. The goal of doctors as ‘man-midwives’  was to take over the provision childbirth services as an exclusive aspect of medical practice, a fact very well articulated in the 1820’s quote below.

Word origins of  “Midwife/midwifery” & “Obstetrix” as the Latin equivalent of “midwife”

0
The historical word ‘midwifery/midwife’ comes from Middle English and reflected the female gender of the care provider. During this time, the idea of ‘adult woman’ and ‘wife’ were often used interchangeably, since the principle occupation for adult women was to care for their family, neighbors and other members of the community.
0
The word “midwife” originally focused more on the noun and its gender — female ‘midwives’ (wives/women), than the verbs/activity of providing childbirth services. Later on, the word ‘midwifery’ focused more on the verbs of providing childbirth services, as male physicians began to refer to themselves as ‘man-midwives‘.
 8
Historically the word ‘midwifery’ was also used in formal medical education to identify the instruction of medical students in normal childbirth practices. Medical textbooks used the word to indicate the study of normal childbirth as well as its possible pathologies, such as a 1832 textbook entiled “The Art of Midwifery and Churgery” (surgery).
0
As recently as 1955, an obstetrical textbook for doctors published in the UK was titled “The Modern Practice of Midwifery & Gynecological Surgery“.
9
The Latin word for ‘midwife’ is ‘obstetrīx‘. It comes from the verb ‘obstāre-‘ or “to stand in front of,” and the feminine suffix ‘-trīx
7
The “obstetrix” was one of three types of women-providers who traditionally assisted mothers-to-be during childbirth. Two of the woman-helpers stood on each side of the laboring woman, steadying her in an upright position or helping the mother squat while pushing.  As the baby was being born, the obstetrīx or midwife typically stood or crouched in front of the laboring woman, assisting the mother as she pushed, helping the baby if necessary and catching the baby as it was being born.

 


18th centuryimages-12

 

Prior to the 19th century, social mores considered the presence of any male, other than the mother’s husband, at a normal birth to be both indecent and improper. Since all doctors were men, this prohibition applied to them as well.

So a very curious German physician dressed himself in women’s clothing and snuck into a midwife-attended birth. Unfortunately, his rouse was quickly discovered.

Even more unfortunate for him, the family reported him to the authorities and he executed for violating contemporary morals.

1820 ~”Remarks on the Employment of Females as Practitioners in Midwifery; Published Cummings & Hilliard – Boston, 1820

Women seldom forget a practitioner who has conducted them tenderly and safely through parturition (childbirth)…
It is principally on this account that the practice of midwifery becomes desirable to physiciansIt is this which ensures to them the permanency and security of all their other business [as a general practitioner].

….where midwifery has been in the hands of women, they have only practiced among the poorer and lower classes of people; the richer .. preferring to employ physicians, and this has been the reason why it has not become universal…

… but if it {i.e. care by midwives} is again introduced among the rich and influential, it will become fashionable; it will be considered as indelicate and vulgar to employ a physician, and the custom {i.e. the ‘female’ practice of midwifery} will become general.

It is sufficiently obvious if the employment of female practitioners becomes fashionable, that it will create a fastidious nicety of feeling, which will make it be thought indelicate to suffer the attendance of a physician…

 It is one of the first and happiest fruits of improved medical education in America, that [midwives] were excluded from the practice; and it was only by the united and persevering exertions of some of the most distinguished individuals that our profession has been able to boast .. this was effected.
 5

semmewise-head-shot

1840-1847 ~ Dr Ignaz Semmelweis, physician-scientist who devoted himself to ending the pandemics of childbirth septicemia in 19th century Austria

A modern-day biography described Dr Semmelweis as:

“…one of the most prominent medical figures of his time. His discovery concerning the aetiology and prevention of puerperal fever was a brilliant example of fact-finding, meaningful statistical analysis, and keen inductive reasoning.

The highly successful prophylactic hand washings made him a pioneer in antisepsis during the pre-bacteriological era {before disposable exam gloves} and in spite of deliberate opposition and uninformed resistance {from other doctors}.”

As a medical student and later as a professor of obstetrics, he worked in the lying-in wards of the world’s largest and most prestigious general hospital — the Allgemeines Krankenhaus in Vienna. In the 1840s, the maternity department housed hundreds of patients at a time, and delivered more than 3,000 babies a year. As was the custom, maternity patients stayed in the hospital for an entire month after the birth, laying around in their beds and breastfeeding their new babies (hence the concept of “lying-in wards”).

Decades before Pasteur and Lister were able to scientifically prove that bacteria caused infectious disease, Semmelweis scientifically established in 1847 that puerperal sepsis or “childbirth fever” in hospitalized maternity patient was a contagious infection spread primarily by medical students and their professors of obstetrics.

Dr. Semmelweis identified the causative factors, saying that:

…. puerperal fever is caused by the examining physician himself, by the manual introduction of cadaveric particles into bruised genitalia.

After performing autopsies on maternity patients who died the day before, med students and their professors unknowingly carried deadly germs on their hands and clothes from the hospital’s morgue to the vaginas of healthy patients in its labor wards.

In Division One, the medical school’s teaching facility for clinical training of doctors, an average of two new delivered mothers died from sepsis each day. This was a two-to-four fold increase in MMR when compared to births in the “Second Division”, which was a teaching ward run by midwives to train midwifery students. The education of midwives did not include dissecting cadavers or performing autopsies.

Having exposed the iatrogenic nature of puerperal sepsis, Dr. Semmelweis went on to develop effective methods to stop the cycle of contagion between the medical staff and their labor patients, which in turn caused more disease and more deaths. The answer started with hand washing in chlorinated lime water (i.e. bleach).

Semmelweis met with an unfortunate and early death at the age of 47  — just 21 years after starting medical school. He went more than a little crazy when he couldn’t get his professional colleagues to acknowledge the nature of this problem or use the simple measures (hand washing in chlorinated lime water) that prevented the spread of this fatal disease.

In his own words Dr. Semmelweis concluded that:

Puerperal fever is caused by conveyance to the pregnant woman of putrid particles derived from living organisms, through the agency of the examining fingers, consequently must I confession that God only knows the number of women whom I have consigned prematurely to the grave.”

~ The Allgemeines Krankenhaus ~
Poorhouse and hospital extraordinaire

290px-AAKH-1784

Vienna’s world-famous general hospital (the Allgemeines Krankenhaus or AKH) was a huge medical complex that occupied a whole city block and at that time was the largest, most comprehensive medical facility anywhere in the world.

Like the famous Hotel Dieu in Paris, the AKH was an icon of the original concept of ‘hospital’ as a place of hospitality for the poor and homeless. Hospital care had little to do with medical cures (there weren’t any!) and everything to do with a dry bed, regular meals and someone to empty a bedpan. But soon after being founded, the AKH became part of the University of Vienna’s medical school, as its high patient census provided a bottomless pit of patients to be used as ‘teaching material’ to be used in the clinical training of medical students from all over Europe. In return for this kind of free medical care, all its patients, including women in labor,  had to let themselves be used teaching cases and clinical material.


1881 ~ Transaction of the Edinburgh Obstetrical Society“, Vol. 6, Session 1880-81, Edinburgh:  A discourse on childbed fever and why nurses who are menstruating are not fit to perform “certain work”

Dr. Keiller: (discussing puerperal fever) “…what he wished to insist on was that the nurses should not live in the Maternity Hospital, but someplace near. He thought that they should specially insist on nurses being very cleanly in their persons, especially during their menstruation.” 

Dr. Taylor alluded to a correspondence which appeared some years ago in the British Medical Journal, affirming the truth … that a woman during her menstrual period was unfit to manipulate ham in the process of curing, the general experience being that ham so treated did not keep

The truth was that these popular beliefs were, as a rule, the result of intelligent observation and sagacious inference, and this one at least, was supported by not only amply testimony, but constantly recurring experience

They were all aware that whilst in some women, menstruation was a comparatively local process, in others it was accompanied by characteristic emanations from the rest of the body, and these, proceeding from the hands and reaching the pork in the process of rubbing, could hardly fail to contaminate it

In the same manner, if these emanations be brought into contact with the raw surfaces which seem to be a necessary contingent of parturition [childbirth], how much more rapidly and certainly will mischief be done! If it affects raw pork, notwithstanding the intervention of salt used in rubbing, how much more rapidly will it be absorbed to the detriment of a living organism

Hence there is great need for the precautions which Dr. Keiller suggests. Not only should the nurses be separately housed, but the grave question forces itself upon us, “Should a menstruating nurses be allowed to [providing care] in cases of childbirth?” 


 1893 to 1931 ~ Dr. J. Whitridge Williams, MD, author of Williams’ Obstetrics textbook; became the most influential obstetrician in the country, historically known as the founding father of academic obstetrics in America.
After graduating from medical at the age of 22, Dr. J W Williams trained in gynecological surgery at Johns Hopkins University Hospital. In 1893 he was appointed associate professor of midwifery* After 2 years Europe for clinical training in obstetrics and pathology, he returned to John Hopkins  and was promoted to full professor of *obstetrics at the JH medical school and chief of obstetrics at JH University Hospital in 1899. He became Dean of the JH School of Medicine 1911.  
3

[**Between 1893 and 1899, the medical profession stopping using the historical word ‘midwifery’ for the medicalized management of pregnancy and childbirth and started calling it “obstetrics” instead, , this avoiding the socially awkward title of “man-midwife”.]

2

1899 ~ Dr. JW Williams’ comments on the disturbing professional rivalry between doctors who practiced obstetrics (historically a non-surgical discipline) and members of the new surgical discipline of gynecology. Dr-JW-WilliamsGeneral practitioners of obstetrics were not trained as surgeons, so when a labor patient needed a Cesarean section, he had to turn the case over to a gynecological surgeon.

This occasioned many bitter disagreements and hot tempers between the two type types of doctors, with raucous name-calling, occasional fisticuffs  and mutual distrust. Dr. Williams was convinced that neither professional could advance until both joined forces to create a hybrid profession of obstetrics and gynecology as a new surgical speciality in America:

“At present, gynecology considers that obstetrics [a separate medical discipline] should include only the conduct of normal labor, or at most … cases that can be terminated without radical operative interference, while all other conditions should be brought to him [the gynecologist]in other words, that the obstetrician should be a man-midwife.

The advanced obstetrician, on the other hand, holds that everything connected with the reproductive process of women is part of his field, and if this contention were sustained, very little would be left for the gynecologist.”


1903 ~ Quoted from Dr J. W. Williams’ famous textbook, Williams’ Obstetric, first edition, published in 1903

Dr. Joulin (1867) and other observers have attempted to solve the problem by calculating the force exerted in forceps deliveries. Thus, on interpolating a dynamometer between the operator and the ends of the instrument, it was found that the tractile force rarely exceeded 80, though in some cases it reached 100 pounds. A greater force than this cannot come into play, as it has been shown that .. 120 pounds is sufficient to tear the child’s head from its body.

DeLeeTxtbk_cutAway_forceps_edit

anatomy and function of obstetrical forceps


1904The 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 1312-132

The 19th century decline in maternal mortality [in Sweden]was helped along by the national health strategy of giving midwives and doctors complementary roles in maternity care, as well as equal involvement in setting public health policy.

From 1900 through 1904, Sweden had an annual maternal mortality of 230 per 100,000 live births… For the year 1900, the United States reported 520 to 850 maternal deaths per 100,000 live births.3  

The maternal mortality rate in Sweden in the early 20th century was only one third that in the United States. This rate was recognized by American visitors** as an achievement of Swedish maternity care, in which highly competent midwives attended home deliveries.

[** Several American obstetricians visited Sweden in the early 1900s to find out why their MMR was so much lower than the US] 


1906 ~ Dr. Gerwin expresses his opinion about midwives: 

…. 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 


1907 ~ other published comments by obstetricians about midwives:

Dr. Mabbott:  …  “un-American”

Drs. Emmons and Huntington: “the overconfidence of half-knowledge, …unprincipled and callous for the welfare of her patients”


1911 ~ Boston Medical and Surgical Journal, 02-23-1911, page 261 {*}

… 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.”

1911 ~ Dr. Emmons, MD: “Obstetrics Care in the Congested Districts of our Large American Cities
For the sake of the lay members who may not be familiar with modern obstetric procedures, it may be informing to say that care furnished during childbirth is now consideredin intelligent communities, a surgical procedure[1911-D, TAASPIM, p. 214]
OR/delivery room used when conducting birth as a surgical procedure & scrub nurse

OR-type delivery room used to conduct childbirth as a surgical procedure; the scrub nurse is setting up sterile trays for the doctor

1911 ~ Drs. Emmons & Huntington:Has the Trained Midwife Made Good?”

The story of obstetrical education in the country is not the story of complete success. We have made ourselves the jest of scientists throughout the world by our lack of a uniform standard. TAASPIM; 1911-C, , p. 207]

1911~ Dr J. Whitridge Williams, chief of obstetrics, Johns Hoskins, author Williams Obstetrics

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 three-quarters of the professors of obstetrics in all parts of the country, … stated that incompetent doctors kill more women each year by improperly performed operations than the … midwife.
8

[This] seem to indicate that women in labor are safer in the hands of …. 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; p.180

 1911 ~ Dr. Ira Wile, MD, New York City

In NYC, … death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives. [1911-G TAASPIM, p.246, 1911]

1911 ~ Josephine Baker, MD, Director,  Midwifery Training program, NYC

DrJosephoneBaker_1908The 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 … .” [1911-G; TAASPIM, p. 224]

That Socrates’ mother was a midwife bears testimony to the honorable nature of such a profession at a time when civilization in one of its highest forms was at its summit. [1911-G; TAASPIM, p. 232]

1911 Dr. Ira S. Wile, MD,;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. 

[**The ‘midwife problem’ usually referred to the problems some doctors were having their efforts to get rid of midwives.]

1911 ~ Dr. Emmons, MD:Obstetrics Care in the Congested Districts of our Large American Cities

I should like to emphasize what may be called the negative side of the midwife. Dr. Edgar states that the teaching material in New York is taxed to the utmost. The 50,000 cases delivered by midwives are not available for this purpose. 

Might not this wealth of [obstetrical teaching] material, 50,000 cases in NY, be utilized to train physicians?” [TAASPIM – 1911-D, p 216]

1911 ~ A Review of the Midwife Situation; by Arthur Brewster Emmons, 2d, M.D. & James Lincoln Huntington, M.D., Boston;

LEGAL SITUATION: In reviewing the midwife situation … far more might be said of the unsatisfactory condition of obstetric practice wherever the midwife exists. Two standards of skill and a divided responsibility inevitably are found.

The midwife must either be a trained obstetrician, or she must become a subordinate, co-operating with the obstetrician, as does our excellent trained obstetrical nurse, relying on his judgment and resting with him the responsibility of the two lives, before a system harmonious and satisfactory can result.

The history of temporizing with the ignorant, half-trained, often malicious midwife in our sister states to-day reads like many another misguided “freedom ” which is virtually a license by the state to practice quackery on an ignorant, unsuspecting public. The women and infants pay for this “freedom” in deaths, unnecessary invalidism and blindness.

Who are to blame? Is it the ignorant public? Shall we blame the legislators?

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.

When such is the popular feeling, we cannot expect much result from the laws as they now exist, or in mere modification of the law. What we must first do is to 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. 

The Boston Medical and Surgical Journal, pages 251-261

1911Dr. J. Whitridge Williams, MD, Chief of Obstetrics, Johns Hopkins University Hospital

….. the ideal obstetrician is not a man-midwife, but a broad scientific man, with a surgical training, who is prepared to cope with the most serious clinical responsibilities, and at the same time is interested in extending our field of knowledge.

No longer would we hear physicians say that they cannot 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. 1911-B

1911 ~  Dr. J.W Williams, MD,

The paucity of material [i.e. teaching cases] renders it probable that years may elapse before certain complications of pregnancy and labor will be observed… This is to the great detriment of the student.

Moreover, such restriction in [obstetrical] material greatly hampers the development of the professor and his assistants by the absence of suggestive problems and his inability to subject his own ideas to the test of experience1911-B, p. 171

images-6

Depressed newborn of unconscious mother still under general anesthesia (anesthetist at far right of photo)


1912Dr J. Whitridge Williams, :

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]

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]

1912 ~ Dr J. Whitridge Williams continues:

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]

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 perfectly plain that the midwife cases … 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] 


1913 ~ Dr. Van Blarcom, MD New York State:

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. 

1913 ~ Dr. Van Ingen and Dr. Josephine Baker, MD; for NYC

Birth Attendant:

 

Midwife

Physician

Total Births (%):

 

52%

48%

Stillbirth:

 

10%

90%

Neonatal Deaths:

 

35%

65%

1913 ~ Dr. Huntington, influential obstetrician of  his day:

… the midwife will work a definite hardship to those physicians who have become well-trained in obstetrics for it will … decrease their sphere of influence.

8

1914 ~ Twilight Sleep: Simple Discoveries in Painless Childbirth by Drs, H. Smith and J. Whitridge Williams, explaining why equal economic compensation between the sexes is not appropriate:

Have you ever considered,” he said, “the economical significance of the fact that three out of every five women are more or less incapacitated for several days each month, and that one of them is quite unable to attend to her duties?

Granting that the two sexes are possessed of equal intelligence, it means that women cannot expect to compete successfully with men. For until they are able to work under pressure for 30 days each month, they cannot expect the same compensation as the men who do so.”  

1914 ~ Dr J. Whitridge Williams, additional quoted from his book “Twilight Sleep”

That word ‘physiological’ has all along stood as a barrier in the way of progress.

“…. the cultured woman of today has a nervous system that makes her far more susceptible to pain and to resultant shock than her more lethargic ancestor of remote generations

.women of primitive and barbaric tribes appear to suffer comparatively little in labor, [while] civilized women of the most highly developed nervous or intellectual type who suffer most

Even in this second decade of the 20th century, … women bring forth children in sorrow, quite after the ancient fashion, unsolaced by even single whiff of the beneficent anesthetic vapors through the use of which the agonies of tortured humanity may be stepped in the waters of forgetfulness.

Such a woman not unnaturally shrinks from the dangers and pains incident to child-bearing; yet such cultured women are precisely the individuals who should propagate the species and thus promote the interests of the race. Abnormal pain as an evolutionary threat to the [Caucasian] race. Considered from an evolutionary standpoint, the pains of labor appear not only uncalled for, but positively menacing to the race.

…… any trait or habit may be directly detrimental to the individual and to the race and they may be preserved, generation after generation, through the fostering influence of the hot-house conditions of civilized existence.

Everyone knows that the law of natural selection through survival of the fittest, which as Darwin taught us … does not fully apply to human beings living under the artificial conditions of civilization. These artificial conditions often determine that the less fit, rather than the most fit, individuals shall have progeny and that undesirable rather than the desirable qualities shall be perpetuated.”

The problem of making child-bearing a less hazardous ordeal and a far less painful one for these nervous and sensitive women is a problem that concerns not merely the women themselves, but the coming generations.

Let the robust, phlegmatic, nerveless woman continue to have her children without seeking the solace of narcotics or the special attendance of expert obstetricians, if she prefers.  But let her not stand in the way of securing such solace and safety for her more sensitive sisters.

… every patient who goes to the hospital may have full assurance that she will pass through what would otherwise be a dreaded ordeal in a state of blissful unconsciousness (i.e. Twilight Sleep drugs of scopolamine and morphine)

“In Johns Hopkins Hospital,” said Dr Williams, “no patient is conscious when she is delivered of a child. She is oblivious, under the influence of chloroform or ether.”

1914 ~ Dr. JW Williams insisted that scopolamine narcosis of women under Twilight Sleep drugs did not cause any damaging hypoxia in the fetus-neonate because neonatal respiratory depression, which delays breathing after it’s born, as actually advantageous to the newborn.

Quoted from the work of Professor Ludwig Aschoff, Dr J. Whitridge Williams explained:

“the tendency to retard respiration on the part of the child may sometimes be beneficial, preventing the infant from inhaling too early, thus minimizing the danger of strangulation from inhalation of fluids. … statistics of the Frauenklinik show that the percentage of infant mortality is low.

As against an infant mortality of 16 percent [160 baby deaths per 1,000 births] for the state of Baden, [Germany] in the same year a report on 421 ‘Twilight Sleep” babies showed a death-rate of [only] 11.6 % [ 116 per 1,000]. For this strikingly low mortality of the children during and after birth under semi-narcosis, explanation was sought of Professor Ludwig Aschoff, the great German authority on morbid anatomy.

He offered the theoretic explanation that slight narcotization of the respiratory organs during birth by extremely minute quantities of scopolamin[e] is advantageous to the child, as it tends to prevent permanent obstruction of the air-passage of children by premature respiration during birth.”  


1915 ~ Dr. P.W. van Peyma, Buffalo, NY

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 [women who use 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. 

1915 ~ Dr Edgar, MD 

Of the 3 professions—namely, the physician, the trained nurse and the midwife, there should be no attempt to perpetuate the … [midwife], as a separate profession. The midwife should never be regarded as a practitioner, since her only legitimate functions are those of a nurse …. [1915-A; p. 104]

Nurse positioning the mother's legs so obstetrician can perform a vaginal exam

Nurse positioning the mother’s legs so obstetrician can perform a vaginal exam

1915Dr. joseph DeLee, MD, obstetrician, founder of the Chicago Lying-in Hospital and Chicago Maternity Center for poor women, author of the “The Principles of Obstetrics”; identified by historicals as one of the two Titans and founding fathers of modern American obstetrics [Dr JW Williams being the other famous’Titian’]

Obstetrics is held in disdain by the [medical] profession and the public.  The public reasons correctly. If an uneducated women of the lowest class may [provide maternity care], is instructed by doctors and licensed by the State, [attending a birth] certainly must require very little knowledge and skill — surely it cannot belong the science and art of medicine[1915-C, p.117]

1915 ~ Dr. DeLee,The Teaching of Obstetrics“, American Association of Obstetrics and Gynecologists

Cover story on Dr DeLee, May 1935

Cover story on Dr DeLee, May 1935

The midwife has long been a drag on the progress of the science and art of obstetrics. Her existence stunts the one and degrades the other. For many centuries she perverted obstetrics from obtaining any standing at all among the science of medicine.

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]

If the profession would realize that parturition [childbirth], viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention.”[1915-C; p.117] 


1917 Dr. Levy, MD

These figures [refers to statistics published in 1931 by Dr. Van Ingen and Dr Josephine Baker for NYC] to 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; p. 44] 


1921 ~ Dr. Levy examined birth-related mortality in Newark, NJ and found a similar relationship to that of Van Ingen’s survey of Manhattan (a 1913 entry above).

Birth Attendant:

Midwife/Home

  Phys/Home

  Hospital

Birth percentage

           38%

      30%

     31%

Puerperal Deaths:

           13%

       34%

     52%

Neonatal MR/1000

           32%

       40%

     34%


1922 ~ Dr. Ziegler, obstetrician 

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.

In this plan the work of the doctors would be limited to the delivery of patients [i.e., as a surgical procedure performed by the physician], to consultant with the nurses, and to the making of complete physical and obstetrical examinations …

This means … the doctors must be relieved of all work that can be done by others —… nurses, social workers, and midwives.” 

Hosp_NatBirth1960_cropped-1-263x300

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; 

..midwives should be trained to act as assistant-attendants … conducting the labor during the waiting period or until the doctor arrives, and assisting him during the delivery. [1922-A, p. 413]


1923 ~ Dr. Ziegler, MD

As to maternal mortality, …during 1913 about 16,000 women died..; in 1918, about 23,000…and with the 15% increase estimated by [Dr.] Bolt, the number during 1921 will exceed 26,000.


1924 ~ Dr. Levy, MD 

….. the stationary or increasing mortality in this country associated with childbirth and the newborn is not the result of midwifery practice, and therefore their elimination will not reduce these mortality rates“, [1924-A, p. 822; Rebuttal by Dr. Levy to published remarks by Dr. Rucker, MD,] 

1924 ~ The Expectant Mother ~ The Mother and Her Child’; Drs. William S. & Lena K. Sadler, M.D; section on childbirth, page 8  ~ emphasis added   

“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.”


1925 ~ Dr Hardin, MD

It should be mentioned however that the US had the worst maternal-infant mortality of any country in the developed world, except for Brazil.

..in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile.”

… according to [Dr.] Howard maternal mortality in the [US], when compared with certain other countries, notably England, Wales and Sweden is appallingly high and probably unequaled in modern times in any civilized country.

Twenty five thousand women die in the United States every year from direct and indirect effects of pregnancy and labor

3 to 5% of all children die during delivery and thousands of them are crippled. [1925-A p. 347 & 350]


1926 ~ Dr. Woodbury

When the Massachusetts Supreme Court (Hanna Porn v. Commonwealth) declared midwifery to be an illegal practice of medicine in 1907, the state’s maternal mortality was 4.7 per 1000 live birth.

By 1913 it had risen to 5.6 and by 1920 it was up to 7.4


1931 ~ A report published by the White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care, noting the wide disparity between safe care provided by midwives and highly risky care of many physicians.

The report’s physician-authors concluded that the care of midwives was safer than the care of MDs, saying that:

“... that untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. (emphasis in original)

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.” 

Midwife-attended normal birth

Midwife-attended normal birth, husband present and supportive

waterbirth_babe_arms02

baby girl 10-15 seconds after birth, just taking her first breath

Tiki & Grace DWtub

Mom & baby 5 minutes after the birth


1933 ~  Study by the New York Academy of Medicine of 2,041 maternal deaths in physician-attended childbirth*

The investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps.

Insertion of forceps in anesthetized mother

Insertion of forceps in anesthetized mother

to follow the natural 60-degree curve of the pelvis, the obstetrician has to pull up, towards the ceiling to delivery the baby's head

In order to follow the natural 60-degree curve of the pelvis, the obstetrician has to pull up, towards the ceiling to delivery the baby’s head

At least two-thirds [of the maternal deaths], the investigators found, were preventable. … newborn deaths from birth injuries had actually increased.

Hospital care brought no advantages; mothers were better off delivering at home. … Doctors may have had the right tools, but midwives without them did better. [reported by Dr. Atul Gawande*in his 2006 New Yorker article “The Score“]


1934The Committee on Maternal Welfare of the Philadelphia County Medical Society

…. expressed concern over the rate of deaths of infants from birth injuries increased 62% from 1920 to 1929. This was simultaneous with the decline of midwife-attended birth and the increase in routine obstetrical interventions, due in part to the influence of operative deliveries.  

DeLeeTxtbk_cutAway_forceps_edit

Excerpt, Dr. Neal DeVitt, MD, a 1975 doctoral thesis: “The Elimination of Midwifery in the United States — 1900 through 1935


1937 ~ obstetrician and famous philanthropist Dr. Alan Guttmacher (associate professor of obstetrics, John Hopkins Hospital) from his book  “Into This Universe”:

Though we cannot make an exact comparison between the maternal mortality in the United States and that in European countries, we can at least make a rough comparison.

All who have studied the problem agree that the rate [of good outcomes] for Holland, Norway, Sweden, Denmark is far superior to our own. Why?  … it must be due to … the patients themselves and differences in the way that pregnancy and labor are conducted in the two regions

What about the conduct of labor in the two regions? Here is where the major differences lie. In the first place, … at least 10 percent of labors in this country are terminated by operation. In the New York Report 20 percent of the deliveries were operative, with a death rate of more that 1 in each 100 of the operated, and 1 in 500 of those who delivered spontaneously. 

Obstetrical anesthesia machine

Obstetrical anesthesia machine

   Very depressed baby,
likely from narcotics
during labor & general
anesthesia during birth
Note –> umbilical cord
is empty of blood and
not pulsing @ the time
of the birth
Very depressed baby, likely from narcoticis during labor & general anes during birth - note pale & flaccid umbilical cord @ the moment of birth

Let us compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. In Sweden the [operative] interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland ….. it is under 1 percent.

What is responsible for this vast difference in operative rates? … Analgesics [narcotic drugs] and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted.

And midwives are trained to look upon birth as a natural functions which rarely requires artificial aid from steel or brawn. [1937-A,p. 133-134]

1937 ~ Dr. Allan Guttmacher, quoting a 1932 speech by Dr. Louis Dublin, President of the American Public Health Association, and statistician for the Metropolitan Life Insurance Company, on maternal-infant outcomes by the Frontier Nurses’ midwifery service in rural Kentucky during the previous two years:

We have had a … convincing demonstration by the Frontier Nursing Service of Kentucky of what the well-trained midwife can do in America. …. The midwives travel from case to case on horseback through the isolated mountainous regions of the State. There is a hospital at a central point, with a well-trained obstetrician in charge, and the very complicated cases are transferred to it for delivery.

..they have delivered over 1,000 women with only two deaths — one from heart disease, the other from kidney disease. During 1931 there were 400 deliveries with no deaths. The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe.

If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life [70,000 preventable maternal-infants deaths a year]. ***

DonnaLyonsDec78-07 stanfo1 Colon smile baby arms dad PScorrd IMG_5184

What are the advantages of such a system? It makes it economically possible for each woman to obtain expert delivery care, because expert midwife is less expensive than an expert obstetrician. Midwives have small practices and time to wait; they are expected to wait; this is what they are paid for and there they are in no hurry to terminate labor by ill-advised operative haste.” [1937-A]


1966 ~ Dr. J. Rovinsky, MD; foreword of Davis Obstetrics:

“There is no alibi for not knowing what is known


1971 ~ Dr. Levy, et al ~ Published report on a California  nurse-midwife pilot program at Madera County Hospital from July 1960 to June 1963 that served mainly poor agricultural workers.

During the three-year program, prenatal care increased and prematurity and neonatal mortality rate decreased at the county hospital.

After it was discontinued by the California Medical Association, the neonatal mortality rate increased even among those women who had received no prenatal care.

This suggests that the intrapartum care delivered by nurse-midwifes may have been far more skillful than that delivered by physicians. Prenatal care decreased while prematurity rose from 6.6 to 9.8% and neonatal mortality rose from 10.3 to 32.1 per 1,000 live births.

It was concluded that the discontinuation of the nurse-midwives’ services was the major factor in these changes.


1975New York Times Magazine

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]


1977 ~ Letter from Dr. Heinrichs, MD., Ph.D., August 1, 1977, Stanford University Medical Center to the State Legislature, strongly opposing AB 1896, the first of 6 failed direct-entry (non-nurse) midwifery licensing bill:

If we want an increase in cerebral palsy, mental retardation, extended hospitalizations for mothers undergoing infections, fistulas, hemorrhages, and other severe and disabling results of neglected childbirth, only then could one endorse bill AB 1896. 


1985 ~ Drs. Feldman and Friedman: Prophylactic Cesarean Section at Term?”

This peer-reviewed paper in the NEJM proposed that the prophylactic use of Cesarean section become new standard of care for all childbearing women, claiming that pre-labor Cesarean surgery would ‘save’ 36 to 360 babies for every one “extra” woman dying from complications of their elective surgical delivery.

p. 1266 ….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000….

This may be the proper moment to recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between 1 in 50 to 1 in 500. … if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of potentially healthy infants at a relatively low cost of excess maternal mortality.

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 or (as our calculations roughly suggest) as many as 36 or 360? …. Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure?

p. 1267….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached?

If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery?

“Prophylactic Cesarean Section at Term?”; Feldman GB, Friedman JA;
New England Journal of Medicine 1985;312:1264-1276


1992 ~  A refreshingly honest comment by Dr. JA Macer, MD, published in an obstetrical journal, admitting that:

It is no longer feasible for individual physicians who have invested 12 years in training at a cost of hundreds of thousands of dollars to dedicate extended periods to observing one normal woman in labor. [Macer JA et al; Am J Obstet Gynecol 1992:166:1690-7].


1996 ~ Report on cesarean deliveries in the Medical Leadership Council (an association of more than 2,000 US hospitals), concluding that:

“the US cesarean rate was medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct.” 


1997 ~ email comment from an obstetrician 

In my opinion issuing a license to a [non-nurse or direct-entry] midwife is giving away a license to kill.   …  I think licensing this activity in the name of competition is wrong. In the name of quality of care it’s wrong. In fact, it’s just plain wrong”       [email correspondence 08:38am 1/17/97 from dk:ob-gyn-l@obgyn.net] 


1998 ~ a rhetorical question posed by Professor Mahmoud F. Fathalla, Professor of Obstetrics and Gynaecology, former Dean of the Medical School at Assiut University, Egypt, and Chair of the WHO Advisory Committee on Health Research.

The question should not be: ‘why do women not accept the service we offer‘, but

‘why do we not offer a service that women will accept?’


2006 ~ Drs De Vries & Lemmens

While looking for a scientific explanation for the extremely high use of obstetrical interventions during labor and birth in healthy women with normal pregnancies, the authors noticed that obstetrical research tended to  follow the popular trends in practice, rather than lead.

This turns the idea the scientific method of inquiry on its head, as  ‘evidence-based decision making‘ is displaced by ‘decision-based evidence-making‘:

… an expectant and patient approach to birth…, where all is considered normal until proved otherwise, produces a science that proves {routine} intervention to be unnecessary.

Alternatively, an aggressive approach to birth…, where birth is regarded as normal only in retrospect, generates a science that demonstrates the need for monitoring and intervention

…. evidence suggests that mainstream obstetric science follows mainstream obstetric practice. (p. 2704).

** De Vries R, Lemmens T. The social and cultural shaping of medical evidence: case studies from pharmaceutical research and obstetric science. Soc Sci Med 2006;62(11):2694-706.


2011 ~ Rachael Ward, director of research for Amnesty International USA and author of: “Deadly Delivery: The Maternal Health Care Crisis in the USA.

When Rachel Ward of Amnesty-USA was interviewed about maternal mortality rates (MMR), she applauded the decline in maternal mortality rates worldwide, but noted that the the United States was one the exceptions.

eight countries are bucking that trend, with the U.S. as the only developed nation among them.

.We’re not waiting for a medical breakthrough, what we’re waiting for here is the political will

She went on to describe maternity care issues in the US as complex, systemic and basically political, and includes the financial interests of the dominant system, and ability of special-interest lobbying groups to endlessly perpetuate the status quo, irrespective of scientific evidence or common-sense.  


2014 ~ Excerpts from an On-line news story about rising maternal mortality rate in the US and work by the Institute for Health Metrics and Evaluation, a global health research center at the University of Washington.

MaternalMortality1_1

After the Institute gathered 20 years of worldwide maternal health data, their research team identified 18.5 maternal deaths per 100,000 live births in the U.S., up from 12.4 deaths per 100,000 births in 1990.

MaternalMortality2_1

Their most recent report, which was later published in the Lancet, American maternal mortality rates over that 20-year period rose at a rate that puts the U.S. in the company of war-torn countries like Afghanistan and impoverished nations like Chad and Swaziland. When Dr. Nicholas Kassebaum, lead author of the study and a Seattle Washington pediatrician, was interviews he stated that

“the US ranks 60th in the world, which is below virtually every other developed nation. … We’re close to triple the (MM) rate of the U.K., and eight times higher than Iceland, the world’s leader”.

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

2016 ~ The Final Solution to the Midwife Problem:

From the perspective of the American obstetrical profession, the ‘midwife problem’ was solved to their satisfaction between 1910 and 1940 by legally eliminating the traditionally independent practice of midwifery in the United States.

Midwives are specialists in
childbirth, postpartum, and
well-woman health care.
They are educated and trained
to recognize the variations of
normal progress of labor and
deal with deviations from
normal to discern and intervene
in high risk situations.

Agnodice_engraving

A modern engraving of “Agnodice”, a midwife and obstetrician in Ancient Greece, who according to legend disguised herself as a man in order to practice as a doctor.

The term midwife is derived
from Middle English: mid = “with”
and Old English: wif = “woman”.
Midwifery is a health care
profession in which providers offer
care to childbearing women during
their pregnancy, labour and birth,
and during the postpartum period.

mid·wife

(mĭd′wīf′)

  1. pl. mid·wives (-wīvz′)
  2. A person,usually a woman, who is trained to assist women in childbirth.
  3. One who assists in or takes a part in bringing about a result“In the Renaissance, artists and writers start toserve as midwives of fame” (Carlin Romano).

transitive verb.  mid·wifedmid·wif·ingmid·wifes or mid·wived (-wīvd′) or mid·wiv·ing (-wī′vĭng) or mid·wives (-wīvz′)

  1. To assistin the birth of (a baby).
  2. To assistin bringing forth or about: “Washington’s efforts to midwife a Mideast settlement” (Newsweek).

Middle English midwif : probably mid, with (from Old English;
see me- in Indo-European roots) + wif, woman(from Old English wīf; see wife).

Word History: The word midwife was formed in Middle English from two elements, mid and wife. At first glance, the meaning of wife would would seem to be clear. However, wife often meant simply “woman” ingeneral in Middle English, not specifically “female spouse” as it most often does in Modern English.

The other element in midwife, the prefix mid-, is probably the Middle English preposition and adverb mid, meaning”together with.” Thus a midwife was literally a “with-woman”—that is, “a woman who is with another woman and assists her in giving birth.”

The etymology of obstetric is even more descriptive of a midwife’s role. Its Latin source obstetrīx, “a midwife,” is formed from the verb obstāre, “to stand in front of,” and the feminine suffix -trīx; –> the obstetrīx would thus literally stand in front of the baby as it was being born.

American Heritage® Dictionary of the English Language, Fifth Edition.

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

Next in series –> Unfinished Draft ~ “Abridgement of Patient-rights, discrimination against certain childbearing women by 2013 amendment to the LMPA ~ AB 1308 “