Five years before Joseph DeLee presented his paper, The Prophylactic Forceps Operation, he embarked on a fierce campaign to end midwifery. His problem with midwives? Obstetrics was, as he put it, “held in disdain by the profession and the public” and allowing “women of the lowest classes” to practice obstetrics would lead the public to believe that obstetrics should not be considered a medical specialty.
At the Sixth Annual Meeting of the American Association for Study and Prevention of the Infant Mortality in Philadelphia in November, 1915, Joseph Bolivar DeLee presented his arguments for the abolishment of the midwife. The new standard for the future of childbirth was obstetrics and public buy-in would be tantamount. As DeLee stated, “In all human endeavor improvement begins at the top and slowly percolates down through the masses. One man runs ahead of the crowd and plants a standard, then drives the rest up to it.”
DeLee, in addition to calling midwives evil, wrong and barbaric, disparages chiropractors and optometrists.
In the discussion that followed, J. Whitridge Williams, who went on to write the Williams Obstetrics, addressed the importance of nomenclature in gaining respect in the discussion section that followed this paper.
I have expressed myself on other occasions before this Association as to the crux of the matter; it is the proper education of doctors. We have just begun to understand what an obstetrician is, and he is much more than a man-midwife. The man who invented the obstetrical forceps was named Chamberlen, and he called himself a “man midwife.” The greatest obstetrician at the end of the eighteenth century in Great Britain was Dr. Thomas Denman, and on the title page of his book, he designated himself “man midwife and accoucheur of the St. Thomas Hospital.” What could you expect from a man whose occupation was man-midwifery? What we need to do is to educate doctors to be competent obstetricians, and the obstetrician is much more than the man who simply delivers the woman. One of the things I objected to in Dr. De Lee’s paper was the use of the word accoucheur. I think that is an opprobrious epithet; it comes from “accoucher” and that means to put a woman to bed, and a man who goes around and calls himself a putter to bed of women is a very poor type. I have great regard for Dr. De Lee, and probably when he hears my criticism, he will not use the term in the same way, but a man-midwife and an accoucheur are two things that raise my ire. The man-midwife has disappeared, the accoucheur is disappearing, and what we need is the scientific obstetricians, and we are only going to get him by a great extension of our obstetrical education.
PROGRESS TOWARD IDEAL OBSTETRICS
Joseph B. DeLee
I desire to state that I am fundamentally opposed to any movement designed to perpetuate the midwife. These are the grounds.
I. The midwife destroys obstetric ideals. She is a drag on our progress as a science and art.
II. The midwife is not absolutely necessary at the present time.
III. European countries, for centuries, have been trying to bring the midwife up to a tolerable standard and, measured even by their low ideals, have failed miserably.
I. 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; it has been proven time and again that it is impossible to make her right—further, a part cannot be equal to the whole, and yet there are those who, crying expediency, are willing to foster and perpetuate this evil.
There is here a struggle between expediency and idealism. The midwife has 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 prevented obstetrics from obtaining any standing at all among the sciences of medicine.
Even after midwifery was practiced by some of the most brilliant men in the profession such practice was held opprobrious and degraded. Less than 100 years ago, in 1825, the great English accoucheur Ramsbotham complained of the low esteem in which he was held by his brother surgeons. He was denied admittance to the Royal College and his colleagues would not dare to be seen talking to him on the street! This opprobrium, to a decided extent, still attaches to the accoucheur and his work. Obstetrics is held in disdain by the profession and the public. The public reasons correctly. If an uneducated woman of the lowest classes may practice obstetrics, is instructed by the doctors, and licensed by the State, it certainly must require very little knowledge and skill—surely it cannot belong to the science and art of medicine.
Ziegler, of Pittsburgh, says: “Both the teaching and practice of obstetrics are generally regarded as the poorest of all the clinical branches of medicine. There must be a reason for this. The lay public will continue to regard with indifference all pleas for the improvement in the teaching of the practice of obstetrics so long as more than 50 per cent of confinements are in the hands of ignorant, non-medical persons, who, as a class, are regarded as capable of doing the work satisfactorily, even by physicians, among whom are certain well-known professors of obstetrics.”
Why should there be a double standard in obstetrics? Is there to be one standard for midwives and one for doctors? Should there be two standards of skill when common sense and science demand only one? Would the surgeons tolerate a renaissance of the cutters for stone? Do the ophthalmologists favor a school for the instruction of optometrists, spectacle fitters? And can anyone deny that the spectacle vendor does much less harm than the midwife? Why not train the chiropractors and Christian Scientists also? They do as much harm as the midwife. An editorial from the Illinois Medical Journal is apropos:
Wants Equal Standards
The committee on medical education of the Illinois Medical Society in its last report calls attention “to the inequitable provision in the Illinois statutes which exacts certain requirements of preliminary education and prescribed medical courses of applicants for medical licensure while practitioners of other systems of healing and midwives are required only to pass an examination, without preliminary educational requirements. It certainly looks like class legislation and legislation which does not conserve the health and lives of the people. If the state board has power under the present practice act, and we think that it has such power, to exact similar educational requirements of other practitioners and midwives, we hereby recommend that this be done, to the end that all licensures shall be placed on an equitable footing.”
The medical schools are raising the standards of medical teaching all along the line. Preliminary education, thorough and complete courses in all branches, even a fifth or hospital year, are being demanded. And yet we are to try to educate, in a few months, an ignorant woman up to responsibilities of cases with mortalities which would stagger the best of surgeons. Is not this a jump backward and should we subscribe to this anomaly, this anachronism in medicine?
The midwife is innocent of the trouble she causes and of the high mortality and morbidity among the mothers and babies. It is not her fault that she is allowed to practice such a delicate profession, carrying such direful responsibilities. If the doctors recognized the dignity of obstetrics she could not exist. Engelman says: “The parturient suffers under the old prejudice that labor is a physiologic act,” and the profession entertains the same prejudice, while as a matter of fact, obstetrics has great pathologic dignity—it is a major science, of the same rank as surgery.
Certainly, having babies is a natural process, and, in the intention of nature should be a normal function, yet there is no one here who can deny that it is a destructive one. We all know that even natural deliveries damage both mothers and babies, often and much. If childbearing is destructive, it is pathogenic, and if it is pathogenic it is pathologic.
I do not have to go far to prove these statements, and will cite only a few facts. That 20,000 women die in the United States every year, during childbirth, is a very conservative estimate. Hundreds of thousands of women date lifelong invalidism from apparently normal confinement, and our local findings are very meager. A few of the less prominent but proven sequences of childbirth are—laceration of the cervix, parametritis postica, chronic metritis, sterility; again—laceration of the perineum, rectocele, pelvic congestion, patulous vulva, chronic infection of the vagina, cervix, uterus, etc.; again—urethrocystocele, cystitis, ureteritis, pyelitis, nephritis—and combinations of all these, leading to incurable invalidism. Of the more evident damages, prolapse of the uterus, and deviations of this organ may be mentioned, and, let this be emphasized, these admittedly pathologic sequences, not seldom, but often follow so-called normal labor.
As for the babies there is a birth mortality of at least 3 per cent in spontaneous deliveries, and there is a larger percentage of brain injuries than can be proven by available statistics.
Thus far I have had in mind only natural deliveries—so-called normal labors. Let us remember the complications of pregnancy and labor, placenta previa, eclampsia, abruptio placentae, ruptura uteri— accidents occurring with startling suddenness and requiring instant treatment. They have a mortality of from 15 to 80 per cent—as high if not higher than any of the complications of surgery. And we are to trust the prevention of these accidents, these diseases, these deaths to ignorant midwives!
If the profession would realize that parturition, viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible even of mention. The double standard of obstetric practice would be abandoned.
It is a general complaint of obstetric teachers that young physicians will not adopt obstetrics for their specialty. That the work is hard, that obstetrics is a jealous and exacting mistress, is appreciated, but neither deters the young man, because the science and art of obstetrics are the most interesting and gratifying in medicine. What does deter him, and it may be said without disparagement, is the fact that his arduous labor and sacrifice of time, of comfort and self, are not appreciated and requited with respect and remuneration. These two go together. If the public would acknowledge the dignity of his specialty it would properly remunerate him for his services. If the specialty were as remunerative as the other departments of medicine it would attract to itself a large number of young men. The capable accoucheurs instead of being rare, as now, would be very numerous and the mortality and morbidity of childbearing women would rapidly approach a tolerable minimum.
But as long as the medical profession tolerates that brand of infamy, the midwife, the public will not be brought to realize that there is high art in obstetrics and that it must pay as well for it as for surgery. I will not admit that this is a sordid impulse. It is only common justice to labor, self-sacrifice, and skill.
It is generally admitted that more women die during confinement in the hands of doctors than among midwives. Williams, in his remarkable and epoch-making paper seems to have demonstrated this as the prevalent opinion. The fact that only 40 per cent of the women of the United States employ midwives does not explain the difference. There seems to be actually a larger number. In England, as the result of stricter regulations for the midwives, their mortality decreased, but the total mortality throughout the land remained about the same. Would these, seeming facts, not indicate that the standard of practice of the doctors required raising, and would it not also follow that we could save more lives by increasing the number of skillful accoucheurs? The energy directed to the training of midwives would bring greater results if spent on the doctors. This would improve the condition of the 60 per cent—and the 40 per cent would be benefited indirectly, also.
We are asked to educate the midwife as a matter of expediency, to provide a little better care for the poor, the ignorant woman or foreigner, and, we are told, though I do not believe it, that 40 per cent of the women in America must have midwives. The 60 per cent employing doctors, are well to do, or at least not paupers—educated, and Americans.
Now, I hope I will not be misunderstood in what I am going to say. I will take second place to no man or woman in my regard for the poor, the ignorant, the foreign born, childbearing mother. Those who know my work among them will bear witness to this. But I have just as high a regard for the well-to-do, the educated and the American woman, and I must raise my voice against a measure which, I am convinced, from 25 years of deep, close, observation and study, will tend to jeopardize her health and her life. While we may, by educating midwives, improve somewhat the condition of the 40 per cent, we will delay progress in ameliorating the evil conditions under which the 60 per cent now exist. For every life saved in the 40 per cent we will lose many more in the 60 per cent.
Ideas and ideals are the hardest things in the world to establish, but once established they are impossible of eradication and they raise the plane of human existence. It is, therefore, worth while to sacrifice everything, including human life, to accomplish the ideal. Witness what is going on in Europe! Knowing this I am willing, for the time, to close my eyes to what the midwives are doing, and establish high ideals. Then all, poor and ignorant, as well as rich and educated— the 40 per cent as well as the 60 per cent will enjoy the benefits of improved conditions.
In all human endeavor improvement begins at the top and slowly percolates down through the masses. One man runs ahead of the crowd and plants a standard, then drives the rest up to it. Search history, biblical and modern, and this fact stands out brilliantly.
Philanthropic workers, everywhere, are convinced that remedial measures, meeting conditions as they exist, only salve the sores of society, and perpetuate the underlying evils.
II. The Midwife today is not an absolute necessity. The midwife is slowly disappearing in America. In the rural districts of Illinois she is almost unknown. Dr. A. E. Diller, of Aurora, found some of the counties did not have a single midwife, they were only in the larger towns and cities. The Secretary of the Illinois State Board of Health says that about 1,200 Midwives are registered, of which 900 are in Chicago.
Of the 101 counties in the State of Illinois Dr. Diller received statistics from 87. There were no births registered by midwives in 37 counties, which means that there are no midwives in these counties. Of the 55,187 births registered in the State outside of Chicago the past year, 51,832 were registered by doctors and 3,353 by midwives.
There are 201 midwives registered in Indiana, of which 125 are in the larger cities, a few in the rural districts. Statistician Carter of the State Board of Health, considers them dispensable.
Dr. Bracken, of the Minnesota State Board of Health, also considers midwives dispensable and believes it feasible to abolish them. He says they do not practice in country districts, but only among the crowded communities of foreigners.
Dr. G. H. Matson, of Ohio, says that midwives are still employed by foreigners, and not in rural districts. He believes it possible to abolish them.
Dr. St. Clair Drake, of the State Board of Health of Illinois, believes we cannot abolish them and that we should train them.
The subjoined was published in the Journal of the A. M. A.:
Country Practitioners Please Notice
To the Editor:—The undersigned, for the purposes of a paper on the midwife question in America, is very anxious to get information relative to the number of midwives in country (farming, lumber, mining) districts, in small villages and towns.
Would the doctors in such districts, villages and towns kindly jot down on a postal card answers to the following questions and mail to me?
1. How many midwives practice in your vicinity?
2. Do you consider the midwives a necessity in your neighborhood? Any other information will be gratefully received.
Fifty-one replies were received and I here again thank those physicians who took the trouble to answer the questions. The doctors write from the following States: Pennsylvania, Virginia, North Dakota, Illinois, Wyoming, Iowa, Arkansas, Ohio, Minnesota, Kentucky, Tennessee, Texas, Indiana, Wisconsin, Vermont, Missouri, Oklahoma, California, West Virginia, Utah, Alabama, Massachusetts, Washington.
Twenty-four doctors say there are No midwives in their vicinity. In El Paso, Texas, 20 to 40 practice among the Mexicans. In North Dakota midwives do not exist in the villages but do practice in the country. Dr. Dach, of Reeder, North Dakota, considers them a necessity as also does Dr. Ames, of Mt. Grove, Missouri, both because of the distances. Dr. Giannini, of Kettle Island, Kentucky, because of the mountainous country, also says they are needed. Of the 51, only 5 physicians say the midwife is necessary; 44 hold her entirely dispensable, two are doubtful. Most of these 44 practice in districts where it is many miles to the doctor and yet they find that they get along without midwives.
From these facts and opinions we may decide that rural districts get along without midwives very well, that these women do not exist in a larger part of the country. It may therefore be said that we do not have to train midwives to care for the rural districts. In the crowded communities, especially industrial centers employing foreigners speaking an alien language, the midwife thrives, but because she thrives we may not conclude she is indispensable. It is exactly in crowded communities that our substitute agencies are able to work with their greatest efficiency.
What has been done to take the midwife’s place?
In the larger cities, Boston, New York, Philadelphia, Baltimore, Pittsburgh, Chicago, substitute agencies are supplanting her, and, what is still more hopeful, even the poor foreigner is becoming enlightened as to the value of medical attendance and is demanding it. By supplying midwives we will keep these women longer in their ignorance. The Prenatal Clinics in Boston indicate the marvelous possibilities in this direction. To those unfamiliar with this work the articles by Dr. Arthur B. Emmons and Miss Mary Beard will prove highly illuminating.
What is being done in Boston is also done in other large cities and can be done in every city, town and village in this country. While the effort required to accomplish all this will be greater than that to give a few midwives a smattering of obstetric knowledge, the amount of good attained will be immeasurably superior and what is more, it is a permanent improvement in obstetrics—real progress.
Since poverty is given as the cause for the perpetuation of the midwife let us see if there be not some way to eliminate poverty at least as far as childbirth is concerned.
The free maternity hospital will take a certain number—always small however, but still growing each year, as the demand among the people for experienced accoucheurs increases. The number of beds in hospitals for women of moderate means is also increasing rapidly. The free dispensaries—or out-clinics are now caring for a very large percentage of the cases. Accurate statistics are very hard to obtain. I would guess that in Chicago, about one-fifth of the births are cared for by institutions of the dispensary type.
The Peter Bent Brigham hospital allows $10.00 per case to young physicians.
Why not endowed accoucheurs as there are endowed visiting nurses? The city, the county, the state could well afford to subsidize the accoucheur, if private philanthropy did not assume the burden. Maternity insurance has been suggested, and, if sickness insurance comes into vogue—provision for the maternity case will surely be incorporated.
The visiting nurses do an immense amount of real good in maternity work. They provide a degree of prenatal care that is unrecognized in our journals. They get neighborhood physicians to attend the women during labor while they care for both mother and baby afterward.
There are thousands of young physicians, who would take cases, now cared for by midwives, were it not considered undignified work— and also undignified to accept such a small fee for the service.
In the mining and factory communities physicians employed by the companies can and do care for the wives of many of the workers. With all these agencies at work it is not an unattainable dream to furnish good obstetric care for all women. The midwife can be dispensed with, she is being gradually eliminated. I feel certain that if every midwife in America were to vanish today, before the week ends every woman in the United States would be cared for—and cared for much better than she is today.
III. It is impossible to train the midwife sufficiently to make her a safe person to attend labor cases.
After what has been said it is superfluous to dilate on this point. Obstetrics is a major science. It requires the highest kind of skill in addition to much knowledge to do even tolerable work. The high class of work and superior knowledge required of the infant welfare nurses, the child saving societies, public health movements, all throw into relief the impossibility of training the midwife for any good purpose.
But all these arguments are unnecessary and insult one’s intelligence.
Finally we have the experience of others. Europe has tried to educate midwives for many centuries and has failed signally. Ekstein, of Teplitz, Austria, has been Chairman of the Midwife Committee of the German Gynecologic Society for years. He is editor of a Midwife’s Annual. He calls the midwife situation in Austria and Germany a state of misery, and envies us our conditions here. I have visited many European clinics and I am convinced that the reason they are so far behind ours in their obstetric technique, is because of the presence of the midwife and the low ideal she establishes.
In Europe the midwife has more standing than she has in this country; the laws she must obey are stricter, they are enforced better than they could possibly be enforced here; she receives a two years’ training in the best maternities under the world-famed professors; she has to take post-graduate courses every few years; she is under the direct supervision of the health physicians—and they supervise; and yet an authority on midwives calls the situation miserable!
If the medical profession fails to establish tolerable conditions in Germany, can we hope to succeed? And if we do succeed what have we accomplished? The answer to this question will be found in the foregoing.
I would refer to the paper of Emmons and Huntington, of Boston, read in Chicago four years ago. Their ideas are identical with mine.
I conclude. I am heart and soul opposed to any measure which is calculated to perpetuate the midwife. In educating her we assume the responsibility for her; we lower standards, we prostitute ideals, we compromise with wrong and I for one, refuse to be particeps criminis. We, for the lesser evil, lose the greater good.
Finally she is not a necessity. The rural districts are already getting along very well without her. The foreign population of the cities is being taken care of better every year and as their education improves will also learn to do without her.