Utah Midwives Annual Conference
March 7 & 8, 1997
I. Overview of the relationship of Midwifery and Medical practice, important vocabulary distinctions:
The important historical difference between the practice of "midwifery" -- the art and science of normal maternity care for healthy women as provided by both midwives and physicians -- as contrasted with "the midwife problem", which referred to the elimination of midwives FROM the practice of midwifery
Hierarchy of superstition, science/pseudoscience -- superstition, "authority" (arrived at by polling the "experts"), case studies, retrospective studies, prospective studies, Randomized Controled Trials -- lack of scientific basis for customary obstetrical procedures as applied in American hospital-based obstetrics
First Bio-Ethics Commission not appointed until 1976 -- before that doctors did not need to distinguish between treatment regimes that were experimental, those which had NO basis in science (authoritative) from those which had a well recognized scientific foundation
II. The History of Politics -- the really ‘BIG picture’
A. The origin of jurisprudence and the Rule of Law
B. Systematic exclusion of women from institutions of higher learning
The discipline of Medicine has only existed as an "applied science" since the century 17th (+1600AD). In contrast, midwifery is not primarily a legal entity but rather is an organic function defined by biological imperatives and the social customs required to meet the needs of women giving birth.
In the early decades of this century, the medical fraternity usurped the power of law to unethically define the independent practice of midwifery as an illegal or unauthorized practice of medicine.
Legally and legislatively speaking, the infrastructure of "modern" medicine was laid down in the late 19th and early 20th century and has remained untouched and untouchable ever since. These 19th century attitudes and policies have created a sovereign classification for physicians and a subordinate, substandard classification for midwives. This tactic has already been dragged along intact throughout the entire 20th century.
In the big picture, the recurring theme is political power, voting rights and women's historical lack of both. The unconstitutional War on Midwives had already been lost by the time women had won the constitutional right to vote.
Historical Background of Midwifery
Õ "The practice of midwifery is as old as the human race. Its history runs parallel with the history of the people and its functions antedate any record we have of medicine as an applied science. Midwives, as a class, were recognized in history from early Egyptian times. The practice of midwifery is closely bound by many ties to social customs and prejudices." [1925-A; Hardin, MD p. 347] ^104
Õ "As a class midwives were recognized in history from early Egyptian times. In the history of European continent the practice of midwifery by the medical profession did not begin until the middle of the 16th century. [1911-E; PriceMD, p.221] ^103
Õ "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; BakerMD, p. 232] ^108
Õ "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. [1911-G; BakerMD, p. 232]
During the Middle Ages and the period of Enlightenment, Midwives had positions of authority and influence in Germany, France, and England, writing well-known treatises on midwifery (the art of normal childbearing) and obstetrics (management of the complications of childbearing).
According to Herbert Thomas, MD, Professor Emeritus of Obstetrics and Gynecology, Yale University and author of Our Obstetrical Heritage -- The Story of Safe Childbirth (1960), “The French midwives as a group were highly influential in advancing obstetrics.”
III. Midwives of Great Antiquity and
their Historical InfluenceA. The mother of Socrates and the wife of Pericles were both midwives. Aristotle speaks of the wisdom and intelligence of the midwives of Greece.
B. Office of the Midwife - Exodus 2 gives us the first ethical principles in the Bible, coming before the Mosaic Code and the Ten Commandments. Simply stated, the Office of Midwife demands that the wellbeing of the mother and baby be put ahead of any political consideration even when doing so exposes the midwife to the possibility of person harm.
C. France’s most famous midwife was Louise Bourgeois, born in 1553, who enjoyed great distinction as a teacher, author and midwife to the Royal Court for 27 years. She delivered the future Louis XIII and 6 children of King Henry IV.
D. Another notable French midwife was Madame Le Boursier Du Courdray -- Louis XVI gave her permission to go into the provences and give free instruction to the midwives. She invented a life-size mannequin for teaching purposes, permitting her to demonstrate the position of the baby and techniques of delivery.
Other French midwives of note were Marie Duges, chief midwife at the time of the French revolution and mother of the famous midwife Louis La Chapelle, born 1769, author of an extremely important midwifery textbook based on the institutional labors of 40,000 women.
E. Celebrated German midwife Justine Siegemundin ("Pious Justine") who was Court Midwife to the Electorate of Brandenburg & wrote an early midwifery textbook published in 1776. It was subsequently translated into Dutch and used in the universities of Germany. She was called a "lantern-bearer in the darkness of ignorance and superstition".
F. Alice Dennis was a Danish royal midwife who attended Anne of Denmark.
G. Jane Sharp was the first English midwife to write a book on midwifery called "The Midwives Book or the Whole Art of Midwifery Discovered"
H. Mrs. Margaret Stevens who delivered Queen Charlotte, wrote a "commendable treatise" call "The Domestic Midwife" giving instructions to midwives in the use of obstetrical forceps.
I. During the 1800s, Florence Nightingale, usually only remembered for her association with nursing, and was especially interested in midwifery and wrote a book on the subject. One of her nurses-- Dame Rosalind (Padget) was the leading spirit in founding the English Midwives Institute in 1881.
The literary works by these exceptionally gifted midwives did much to contribute to the understanding of normal labor and birth by “medical men” of the day. These midwifery textbooks, along with the work of the vivisectionists, laid the foundation for the classical obstetrical texts written during the renaissance period. The body of knowledge which has became the modern-day surgical discipline of obstetrics is directly traceable to these early midwives.
IV. Influence of early physicians (1st thru 19th century) on maternity care, midwifery, midwives and obstetrical practice
A. Soranus -- Greek physician born in Ephesus, practiced in Rome during late first century. Of midwives he commented:
" She must love work in order to persevere through all vicissitudes... she will be unperturbed, unafraid in danger, able to state clearly the reasons for her measures, she will bring assurance to her patients and be sympathetic."
B. Ortolff von Bayerland, physician of Wurzburg in the middle of the 15th century author of the Little Book for Women, advising that:
"Every woman who can do it should in time provide herself with an experienced midwife, one with gentle hands, a fearless and not too talkative one".
C. Ambroise Pare, born in France in 1510 His great contribution to maternity care was the reintroduction of the obstetrical maneuver known as podalic version or the turning of a baby in the womb and extracting it by the feet in complicated cases. Before the development of aseptic surgical methods and anesthesia, this was the only way to rescue a live baby although only at the risk the mother’s life due to the danger of introducing infection into the uterus. It was this obstetrical operation that brought surgeons into childbirth and caused them to consider obstetrics as suitable to their dignity. As a result they began more and more to encroach upon the functions of the midwife.
D. The Champerlin Family , early 1600s -- Father, several sons and several grandsons all shared in the invention and proprietary use of obstetrical forceps but kept them a secret for almost 150 years. When they were sold, they did not divulge the principle which made them effective and only gave the new owner one blade which was, by itself, a useless hoax.
V. Historically Unsafe Maternity Practices -- When maternity hospitals came into being the horrifying potentials of puerperal sepsis -- killer extraordinare of childbearing women -- became manifest. At times, 7 out of ten women admitted to Paris hospital for childbirth died before the epidemic subsided.
The battle to educate doctors out of their prejudice and require them to apply scientific principles to obstetrical medicine fell to 5 unsung heroes:
A. Charles White of Manchester, England, (1728) author of "A Treatise on the Management of Pregnant and Lying-in Women" which counseled the quarantine of infected cases. Robert Collins, Master of the Rotunda Hospital in Dublin 1826 to 1833, adopted White’s methods, with successful care of 10,785 maternity patients with only 58 death (rate of 1:185)-- all from cause other than puerperal sepsis.
B. Alexander Gordon of Aberdeen, Scotland, born in 1752, was the first to clearly demonstrate the infective nature of puerperal sepsis. "Like Holmes, Semmelweis, and Pasteur, all of whom came after, he knew the truth that could save countless lives, but like them also he received for his pains chiefly abuse and calumny." Dr. Gordon died of pulmonary tuberculosis in 1799 at the age of 47.
C. Oliver Wendell Holmes of the Cambridge, Massachusetts, (1809) and was the only one to lived long to see most of the things he and others fought for become established. After a year of law school he entered the Harvard Medical School and spent 3 years as a medical student in Paris and Edinburgh. In 1847 he because professor of anatomy and physiology at Harvard, a position he held for 35 years. After the death of a colleague who became infected after performing an autopsy on a victim of puerperal sepsis, Dr. Holmes began to investigate all the evidence he could gather, noting especially that death of several childbearing women attended by his friend shortly before his own death.
He argued against the prevalent medical theory that ascribed infection to an element of chance. He responded by say: "It is not chance that accounts for a single practitioner having 16 fatal cases in a single month". He first published his observation in The New England Quarterly Journal of Medicine and Surgery in April of 1843. Little attention was paid to his theory. A decade later he published it again, warning that a doctor should stay away from maternity patients until it could be established that he was not the source of the infection.
Holmes was not only opposed but ridiculed by the highest authorities in the American obstetrical world. His most famous opponents were Professors Meigs and Hodge of Philadelphia, both very influential leaders of their time. Dr. Meigs attributed the deaths to accident or Providence and Hodge taught his medical students that they should "divest their minds of the dreamt that they could ever carry the horrible virus". ."
Later he wrote about the rejection of his ideas: "But I think I shouted my warning louder and longer than any of them and I am please to remember that I took my ground on the existing evidence before the little army of microbes was marched up to support my position. I defended by position with new facts and arguments and not without rhetorical fever at which after looking down for half a century I might smile if I did not remember how intently and with what good reason my feelings were kindled into the heated atmosphere of superlatives".
D. Ignaz Philipp Semmelweis of Vienna, Austria, born July 1, 1818, in Budapest. Refered to my medical historicians as "A dark page in the History of Midwifery" -- "like many other great benefactors of mankind, he did not live to see his work accepted".
Dr. Semmelweis received his degree in medicine in 1844 and took an assistantship in the Vienna Lying-in Hospital were he was given a degree of Master of Midwifery. The Lying-in Hospital was divided into two "clinics", one for medical students and one for midwives. At the time that Semmelweis took on his role as assistant to the chief of the hospital, the maternal mortality in the First Clinic (staffed by medical students and "attending" physicians) was four times that of the Second Clinic, staffed by midwives. The opportunity afforded to Semmelweis for comparing the condition in the two clinics was an important factor in solving the "mystery" of puerperal sepsis.
In 1846 there were 459 deaths from puerperal sepsis alone in the First Clinic compared to 105 in the Second Clinic, and "even this appalling figure does not tell the whole story for often cases of puerperal fever in the First Clinic were transferred to the general hospital where the patients died. Semmelweis was greatly impressed by these figures and spent his whole time studying the situation -- in the library, in the autopsy room and at the bedside" of childbearing women.
"The reputation of the First clinic was so bad that many heartrending scenes occurred when women found that had been assigned to that division instead of the school for midwives. Added to the horrors of the place were religious ceremonies where priests in their robes, preceded by an attendant ringing a bell, went all through the wards to administer the sacrament to a sick woman. Semmelweis recorded, "Even to me myself it had a strange effect upon my nerves when I heard the bell hurried past my door; a sigh would escape my heart for the victim that once more was claimed by an unknown power."
"One group of women in the clinic particularly interested Semmelweis, namely the mothers of so called street-birth. These were births that took place usually on the way to the hospital, in halls, doorways, and similar places. It was noted that these women were singularly free from childbed fever."
Like Oliver Windle Holmes, Semmelweis was also greatly affected by the death of a colleague who died from blood poisoning acquired after puncturing is finger with a dissecting scalpel. Semmelweis was convinced that Dr. Kolletschka died from the same malady that carried off so many lying-in women. At the time he asked himself, "Did the individual whom I have seen die from an identical disease also have cadaveric material carried into the vascular system? To this question I must answer Yes!"
"Owing to the system of teaching at the hospital, professors, assistants and medical students had frequent reason to come in contact with cadavers. Semmelweis sought means by which any such material adhering to the hands of physicians and medical students could be destroyed. In May of 1847, he began to insist on the use of chloride of lime solution as a disinfectant following the washing of the hands. the result of this simple innovation was that in the year 1848 only 45 women died out of 3556 patient in the first clinic (1:79), while there were 43 deaths out of 3219 (1:74) in the Second Clinic. In the months of March and August of that year, there were not deaths at all in the First Clinic.
For Semmelweis this established three things. It explained his observations about street-births, it accounted for the low mortality in the Second Clinic where neither teacher not midwifery pupils came in contact with cadavers and it fixed in his mind the hypothesis that puerperal sepsis was caused by any kind of decomposed animal organic matter, whether from a living person affected with he disease.
With the miraculous results that Semmelweis obtained it would appear that no further proof of his doctrine would be necessary. But, as has been said, men seldom really change their minds; they simply rearrange their prejudices. The big-wigs in the obstetrical world were not ready to accept any such radical change in thinking. Semmelweis himself acted foolish in the matter. Thinking that his doctrine would in some way carry itself forwards he did nothing about publication, although friends pleaded with him to do so. When in 1861 he finally did publish his book, it was to long and wordy and greatly in need of editorial revision. What William Sinclair said was eminently true: "If Semmelweis could have written like Holmes his Aetolgie would have conquered Europe in 12 months."
In 1850 Semmelweis took a nonpaying position as honorary senior physician at St. Rochus Hospital and with his reforms reduc3d the maternal mortality in one year to less than 1%. In July of 1855 he was appointed professor of Theoretical and Practical Midwifery at the University of Pesth. The very first year of his professorship the mortality in his clinic was reduced to 0.39%, lower than that achieved in any clinic in the world. He now had two successful demonstration in Budapest but still abstained from giving his doctrine authentic publication.
His theories were rejected by the best and most influential members of the "scientific" world. Even the father of cellular pathology, the great Virchow, believed that weather conditions had much to do with epidemics of puerperal sepsis. His book was almost universally ignored. "The result was that he began writing open letter with scathing accusations, denouncing one man before God and the work as a murderer. In 1863-64 the initial steps of a final mental deterioration began to be manifest, his letters became even more abusive, one being addressed to all professors of obstetrics. The end came in 1865 shortly after he was admitted to a sanitarium. At that time one of his doctors noted an infected wound in the middle finger of his left hand and "as if Fate had decided to write with a pen dipped in irony," Semmelweis died from the same type of infection as did his fried Dr. Kolletschka, in whose death he had seen revelation."
Following Semmelweis’s death the doctrine make very little progress until the scientific justification came about through the work of Pasteur, who discovered the bacteria which were the primary cause of puerperal infection. The final evidence was supplied by him when he found the streptococcus in the discharges of dying women and also in their blood stream.
E. Louis Pasteur -- Identified the role of microorganisms in human health in 1879. He proved that puerperal sepsis was caused by streptococcus and could be prevented by the use of sterilization. Dr. Pasteur was originally exposed to the ideas of sterilization while working with his father who owned a winery and used such methods to keep the wine from turning to vinegar.
Due to this discovery, puerperal sepsis has fallen from the number one killer of women in childbirth to the number 4 (1950) -- heart disease, hemorrhage, and toxemia’s of pregnancy are all more potent. The figures from one large American hospital tell the story: From 1929 to 1949, there were 46,093 live births; for the first 8 1/2 years, there were 17,916 births with 40 maternal deaths from infection (1:448). In the last 9 1/2 years there were 28,177 birth with but 4 maternal deaths from infection (1:7044).
In the sad story of puerperal sepsis, these men all gave the world the great truths about the dread iatrogentic disease caused by medical ignorance "but in no instance were their words taken seriously by the medical world until years after they had been uttered."
VI. Medical Politics and Medical Politicians of note -- 1896 to 1940
A. intentional systematic suppression of Independent midwifery as practice by midwives -- Transactions of the Association for the Study and Prevention of Infant Mortality -- published between 1910 and 1915
B. Work of Dr. Whitridge Williams, original author of "Williams Obstetrics"
C. Writing of Dr. Joesph DeLee, inventor of DeLee Mucus Trap, routine episiotomy and other interventions, was willing to have unnecessary deaths of women to help him achieve what he referred to as "Progress Toward Ideal Obstetrics"
VII Unintentional elimination of the quality of "midwifery" as practiced by physicians -- statistical data documenting the deleterious effects caused by the loss of the midwifery model of care
A. 1932 Kentucky Frontier Nurse-Midwifery Service quote acknowledging the unnecessary deaths of 10,000 mothers and 60,000 babies per years due to lack of midwifery model of care.
B. 1951 --founding of the American College of Obstetricians and Gynecologists
VIII Modern Politics
A. 1976 Bowland Decision and abortion --
B. Beckman-Perry, Julia Kessler Lange
IX. Modern Dilemmas -- Why unity between midwives is essential to the success of independent midwifery
A. Sensible actions to take if you think the practices of a sister midwife are dangerous (do NOT go to the District Attorney)
X. How do we use this information, Where to we go from here?