The Hundred Years War Against Midwives
In order to respond to the political challenges facing midwifery for the 21st century, and avoid repeating the mistakes of the past, we midwives need to know our own history -- from the most ancient records of midwifery (1300 BC) to modern developments such as the NARM certification process (1996AD) -- a span of almost 3000 years. Of special importance to understanding "the big picture" is the period which I refer to as "The Hundred Years War Against Midwives".
Historically, the practice of midwives was and still is far safer than the same kind of care provided by physicians. Globally, midwives have long been recognized as guardians of normal birth and a necessary aspect of safe maternity care, providing laboring mothers with a vital quality of emotional support that would otherwise be absent.
In early 1900s, Five industrialized countries with the best maternal-infant outcomes had midwifery-based models of care for healthy mother and obstetrical care for complicated ones. Five that had the worst had physician-centered maternity systems with the United States being one of the bottom five.
None the less, in 1896 the medical community in the US embarked on a well-documented, well-coordinated, and well-financed campaign to eliminate the midwife from the practice of her own profession. Of particular importance were the years from 1896 to 1920 -- a time when women did not have the right to vote and when many practicing midwives were immigrants who did not read or write English. This period marked the beginning of the end of independent midwifery in the US as it had been practiced for hundreds of years.
During this time a small group of influential physicians (including Drs. Williams and DeLee) launched an official campaign to "Eliminate the Midwife". The master plan to abolish midwives was not the result of any categorical deficiency of midwives or a new medical "discovery" that made midwifery skills obsolete. It was instead based on the self-interest of the medical community who wanted the "clinical material" of midwives for the training of medical students. These medical politicians sought to increase the status and income of physicians and promote a more flattering "scientific" image of the profession of medicine. However, this illogical recommendation did not itself have any scientific basis and required ignoring world-wide statistics for maternal mortality and morbidity which argued against such a plan.
In order to pursue this nefarious plan, they had to completely ignored two crucial facts. First -- childbearing itself in healthy women is not fundamentally dangerous. It was poverty, overwork and forced childbearing that were the genuine problems facing mothers and babies of the era, which contibuted to an alarming rate of death and disability.
Secondly, it failed to account for the serious harm -- including the death of both mother and baby -- which could and did result from the routine use of medical and surgical interventions. Most unfortunate of all, Most unfortunately, these harmful interventions did not address the underlying health problems of poverty and overwork.
The underlying motive was to compete with German medical schools, which included clinical training in obstetrics for their students and enjoyed a superior reputation with the European aristocracy. In the early 1900s, obstetrical education in the United States was not based on clinical training -- that is actual hand-on practice, but rather textbook learning, lectures by professors and "observation" of care rendered by others. This meant that many new physicians began a general practice, which included childbirth services, without any first-hand experience or practical skills. As a result, the USA had one of the worst maternal-infant outcomes among the 25 industrialized countries and was considered something of a "laughing stock" among the "First World" or industrialized countries.
The goal of this plan was to make a large number of low income and immigrant women available to medical schools as "clinical material" for the teaching of medical students while eliminating the economic competition from midwives. This plan was implemented over the objections of many other physicians of that time period who had direct knowledge of the practice of midwives and knew the truth -- it was not midwives who were causing the higher maternal and perinatal mortality rate of the United States.
At the time this hostile-takeover of normal maternity care was being engineered by American physicians, the five industrialized countries with the best maternal-infant outcomes had midwifery-based models of care for healthy mother and obstetrical care for complicated ones. The five that had the worst had physician-centered maternity systems with the United States being one of the bottom five. After the plan to suppress midwives was implemented, the maternal-infant mortality in the US actually rose dramatically and did so in direct proportion to the increase in physician-attended births and corresponding drop in midwife-attended births.
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". This propaganda campaign misrepresented the dangers of childbirth and inflated the abilities of medically-based care to eliminate them, while denigrating midwives and falsely accusing them of the unsafe practices which the doctors themselves were guilty.
The campaign 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 clients of midwives. Women did not have the right to vote at this time and the common perception was that the practice of midwives, (i.e., 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 ($5-10).
The legal and legislative aspects of the campaign included a strategy to make the practice of midwives illegal where every possible. In areas where midwives has already achieved legal status, the tactic was to abolish them by ever-escalating educational requirements and regulatory controls. Furthermore, it included a policy preventing the establishment of midwifery training programs and blocking the licensing of midwives. 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 become trained in midwifery in order to provide pregnancy care to healthy women). Licensure status 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.
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.
Interestingly enough, during this same period of time, domiciliary or home-based birth services were a normal part of the care provided by hospital -- they were referred to as "outdoor services". They were remarkable for the lower number of complication, especially puerperal sepsis and their outcome statistics were described as the goal or standards to which hospital should aspire. Unfortunately, as indigent women were brought into the system as "clinical material" it was discovered that they could actually be expected to pay a small sum for their 2 week stay ($1.28 per day) 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 fodder for teaching cases but an added source of income to the hospital. The history from then til now is the downhill story of how childbearing has been and still is being changed from a personal, woman-centered and spiritual event that occurred in the home and the presence of a supportive family structure to that of an impersonalized, masculinized, medicalized, hospitalized "techological event" and far too often, a "surgical procedure" that has in contemporary times become the goose that lays the Golden Eggs of the hospital industry and organized medicine to the detriment of our society.
The facts revealed in professional journals published between 1910 and 1915 documenting the suppression and attempt to eliminate the independent practice of midwives are even more chilling when one realizes that this "Grand Plan" or blueprint for eliminating the competition of midwives is still alive and well at the end of the 20th century -- the same propaganda, the same strategies, the same disingenuous remarks about home-based birth services, the same misrepresentations and misleading characterizations of non-nurse midwives, the same comments that the licensing of midwives is to grant a license to kill.
In short -- a political agenda with an economic goal from which the practical wellbeng of mothers and babies is conspiciously absent. Approaching this serious situation without being fully informed means that midwives misunderstand the underlying motives and methodology of medical politicians. As a result, our collective professional and individual responses often miss the mark. In many places, mothers and midwives are still loosing the 100 years war. Our future of the next generation depends on us.
If knowledge is power, then we as midwives must empower ourselves by knowing exactly how a few well-placed obstetrical professors pursuing the goals of medical education managed to take normal maternity care out of the hands of women and put it into the hands of the hospital industry despite the total lack of scientific justification for this reversal of common sense and the staggering and unjustifiable cost, both monitary and in reduced wellbeing by mothers, babies and new families.
With this knowledge base, it is my contention that the midwifery community can repair the damage done to the reputation of the midwifery model of care. We must reverse this historical disinformation campaign of a 100 years so that our daughters and grandchildren will have the legal option of giving birth at home, attended by the midwife of her choice. Equally important to us all is that the option of home-based midwifery care will be included in our national maternity care policies, provided as an option by HMOs and be reimbursed by 3rd party payors.
