The Fall of Midwifery and the
Ascendancy of Medicalized Childbirth
The Fall of Midwifery and the
Ascendancy of Medicalized Childbirth
The Hundred Years War Against Midwives started in earnest in the late 1800s. By 1910, a well-financed, organized and aggressive campaign -- fueled by the criticism of medical education contained in the Flexner Report -- was well under way. The battle plan was devised by medical schools administrators and professors of obstetrics who hoped to completely vanquish their prime competitors, the independent midwife.
This war was waged in the legislature at a time when women did not have the right to vote. It was waged in the courts at a time when the testimony of doctors was unquestioned and unburden by the necessity to prove any factual basis. It was waged in the public press with a viscous propaganda campaign disguised as a noble attempt to “raise the public consciousness”. This counterfeit excuse for public education 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, they failed to mention 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, those harmful interventions did not address the underlying health problems of poverty and overwork.
Strategies of Choice in the
Suppression of MidwivesThe strategy of first choice in this campaign was making the practice of midwives illegal through legislation. An example of this kind of law was one in New York that read “...no person other than a duly licensed registered physician shall practice midwifery or be registered as a midwife until she shall has received a license to practice midwifery from the State Commissioner of Health.” (New York) Note that physicians were authorized to practice midwifery where as midwives were not. In modern day financial terms, this would be described as a leveraged buy-out.
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.
In Massachusetts, the medical establishment used circuitous and illlogical reasoning in a political strategy called "saying it makes it so".
“In 1894, in the laws passed for the registration of physicians, there is no mention made of the midwife. Whether intentionally or not, she was thus excluded from the legal practice of her profession”. Emmons et al, p.259
The author uses the absence of the term “midwife” in a law related to the registration of physicians as proof that the midwife is “excluded from the legal practice of her profession".
Another important tool in the suppression of independent midwives was a policy of preventing the establishment of midwifery training programs and the licensing or certification of midwives. This was to keep midwives from acquiring the legal protection of an independent profession. Many “medical men” of the day complained that licensure “would give the midwife to much dignity and importance” (Mallott1907). In areas where midwives were already trained and licensed, the tactic was to suppress them by ever-escalating, educational requirements and ever-tightening regulatory controls.
First, Catch your Rabbit
A remark by J. Milton Mabbott, MD in his paper entitled “The Regulation of Midwives in New York” (American Journal of Obstetrics, 1907, p. 523) describes using the law as a trap to get rid of the unwary midwife. Dr. Mabbott says “ ...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.”
This term borrowed from the vocabulary of hunting, describes a mentality of first trapping a small defenseless animal who means you no harm and then after the helpless “rabbit” is captured in the hunter’s trap, one can easily and leisurely polish “it” off however one pleases. Even worse, the concept revolves around using the Rule of Law to achieve an unethical goal. In modern law, this concept is referred to as “turning the patient’s shield into the physician’s sword”. In this instance, laws that were suppose to protect the midwife were used against her.
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. This was one aspect that particularly irked the medical community --- the very idea of “medical men” ( as doctors 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! 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 unchallanged 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”.
This tactic is still used today in event of a complication to charge midwives with criminal negligence . No matter how soon in the course of events the midwife transfered care, critical doctors frequently say "you should have done it sooner" and this personal opinion of the physicians becomes the basis of legal action against the midwife.
Removing the word "Midwife"
from the Birth Certificate LawLast but certainly not least in the weapons of the medical establishment was a strategy to remove the word “midwife” from the birth registration statutes. This meant that 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.
Free & Low-Cost Substitutes for Midwives
-- A Tool of AbolitionThe successful abolition of midwives also depended on developing free & low cost substitutes for 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. 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.”
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.
Knowledgeable & Midwife-friendly physicians
Vocal in their support of midwives.The master plan by the medical politicians in the US to abolish midwives was not based on any categorical deficiency of midwives or any new medical “discovery” that made midwifery skills obsolete or substandard. 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 few among the lay public realized this. 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. 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 exposes the institutionalized prejudice against midwives.
For example, in 1915 Dr. P.W. van Peyma, Buffalo, NY, who reported 40 years of experience working with midwives and was a member of the Board of Examiners in Midwifery for Erie County 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 ....”.
Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after analyzing the work of the Frontier Nurses’ midwifery service in rural Kentucky, made the following statement on May 9, 1932:“ 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.”
These statistics identify a total of 70,000 unnecessary deaths year after year that were simply preventable by skilled midwifery care. This means that half of all maternal deaths during the 1920s, 1930s and 1940s and 1/5 of infant death were avoidable. This was reported by a physician of impeccable credentials more than 60 years ago and yet, the contributions of midwives and the midwifery model of care continued to be ignored at best and eliminated where possible.
In contemporary terms this prejudicial process is known as a “pre-cognitive commitment” and describes making a commitment to a plan of action prior to having full or accurate information. Modern day obstetrics is still predicated on this erroneous “pre-cognitive commitment” set into place during this time period and remaining unexamined by mainstream medicine today.
German Allopathy -- then as now--
the “Gold Standard” for US Doctors.Unfortunately, this corrective information was ignored by those who were committed to their professional self-interest. The underlying motive was to compete with German medical schools, which included clinical training in obstetrics for their students in the large charity hospital of the European continent and enjoyed a superior reputation as compared to the United States. As Dr. Zeigler put it in 1912: “So much is needed before we can hope to give to the students graduating from our medical schools adequate training in obstetrics and before we can hope to compete with the German medical schools.” [1912-B, p.224] It is an interesting note that Germany itself was one of those countries that had a midwifery-based system in the early 1900. Even today, German law requires the presence of a midwife at every birth, even when obstetrical care by a physician is necessary.
In fact, European countries generally had midwifery-based models of care and very much better maternal-infant outcomes than the US. The bottom line in the War on Midwives was that medical politicians coveted the “clinical material” (i. e., potential teaching cases) of midwives' clients for the instruction of medical students. Better educated and well-to-do women patients ("paying customers") were not deemed “appropriate” for the training of medical students. However, the “class” of childbearing woman traditionally cared for by midwives, described as “poor, ignorant and foreign-born” was seen as “suitable clinical material” for young medical students. One must never forget that this educational commodity repeatedly referred to as "material" was actually the warm human bodies of poor women with few other options who offered their childbearing
The campaign to achieve parity with German allopathy also included the idea that routine use of chloroform, episiotomy and forceps were an important “improvement” in maternity care and that it was “unethical” to deny such “advantages” to the women who employed midwives. Many modern-day obstetricians still believe that episiotomy is an advantage denied to women who choose natural birth or a midwife.
Every birth attended by a midwife seen as
a “waste” of “good clinical material”.Physicians soon convinced themselves that every birth attended by a midwife was an obvious “waste” of “good clinical material”. This plan sought to kill two birds with one stone. First, it usurped the clients of midwives as teaching cases for medical students, making medical school administrators extremely happy. Second it “elevated” the status of obstetrics by removing “stigma” of being associated with non-medical women practitioners. The common perception was that the practice of midwives, (mere “women”) reflected negatively on physicians and was considered to be bad for physician “morale”. If a mere woman, not formally educated in medicine, could deliver babies, then childbirth as 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 ($2.50). Getting rid of midwives eliminated free market forces and thus helped to drive up fees for maternity services to $10-15 (an increase of 4 - 6 times).
Domiciliary Birth Services -- then and now
The truth about Midwives and the Midwifery Model of care is plainly apparent in the stastistics of the early decades of the 20th century. What is true about the care of midwives is that it is safer and more satisfactory for those mothers who have choosen a spontaneous labor and birth without the aid of labor stimulants, narcotic pain medication or anesthesia at the time of birth that any other form of care.
As midwives we have nothing to be ashamed of and everything to be proud of. I once heard someone say that "Truth didn't need to be defended, just revealed". The more one investigates the history and contemporary practice of midwifery, the more one cannot excpate the obvious conclusion -- that midwives are the safest, most economical and most satisfactory form of caregiver for healthy mothers experiencing a normal pregnancy and homes of the best and safest enviornment for the vast majority of healthy families.
