In 1910 influential obstetrician declined to consider the other excellent models of care available at that time. One of the biggest hindrance to these other options was a systematic bias against women as healthcare practitioners. The other was their desire to re-invent obstetrics as a stand-alone surgical specialty, which clouded their objectivity.
These doctors were not ill-intentioned, just a product of an era that had strict class and gender lines. In American, midwifery was on the wrong side of both.
While these doctors were mortified that many European countries had far better outcome statistics than the US, they weren’t willing to consider the excellent model used in Sweden since 1881, or even ask why they consistently had better outcomes and dramatically lower rates of maternal mortality than the US.
In 1900, Sweden’s MMR was 200 maternal deaths per 100,000 in 1900, while 665 new mothers died per 100,000 live births for the same period in the United States. The already huge disparity between the US and Europe continued to climb steadily and by 1925, there were 1,200 maternal deaths annually per 100,000 — a 6-fold difference.
What was Sweden’s big ‘secret’? Nothing special or different from other European countries — they maintained a public health system that included a large number of well-trained profession midwives. These women practitioners provided maternity care as independent practitioners, consulted with general practice physicians when they needed advice, and called on them whenever their patients needed medical care.
In 1881 Sweden passed national laws that required all of its midwives and physicians to learn and scrupulously use the newly-discovered principles of asepsis and appropriate sterile technique when attending births and caring for new mothers and new babies.
Other European countries had similar midwife-centric maternity care systems and laws on aseptic technique, but somehow Swedish midwives, working in a supportive and mutually-respectful partnership with their country’s doctors, seemed to do it best.
But in America, strict gender roles, gender bias and gender discrimination were ubiquitous and fully lawful. This was particularly unfortunate in the context of midwifery, as the maternal-infant mortality statistics for midwife-attended births were consistently and substantially better than those of physicians.
Oddly enough, the obstetrical profession acknowledged this, but then explained away its relevance. First they said midwives delivered more women who had given birth before (multipara), which generally have shorter labors and easier births, while MDs were convinced that they attended a disproportionally higher number of first-time mothers (primipara), which were more likely to have longer labors and develop complications.
The other explanation for the better outcomes of midwives as contrasted with physicians was attributed to the poor quality of medical education for American doctors when compared to Europe. European medical schools provided its med students with lengthy and high-quality clinical training that required them to deliver a minimum of 20 childbearing women under strict supervision by their professors.
In the US, minimum medical training in the management of normal childbirth consisted of merely watching one’s professor deliver 6 laboring women. When these new doctors set out to practice, it was customary for them to use forceps and perform any other childbirth-related surgical procedures even when they had absolutely no hands-one training in medical school, never seen the procedure performed as a medical student, and had zero prior experience.
The reasoning of these obstetrical leaders was simple: If “uneducated” midwives (their words) could to do a credible job without having attended medical school, then surely improved medical education, with additional clinical training and hand-on teaching of advanced surgical skills, would produce doctors who could work circles around midwives.
It was assumed that such superior skills would allow MDs to effortlessly manage normal childbirth and successfully deal with any complications that might develop. This new crop of better educated physician-surgeons would easily render the profession of midwifery totally obsolete and ultimately irrelevant.
Best of all, the systemic removal of midwives from the “the birth business” (their words) freed up what was referred to as “obstetrical material” — that is, teaching cases or the much coveted clinical material. By eliminating midwives, poor women would have no option but to come to teaching hospitals, where their births would become ‘material’ for the improved clinical training of medical students.
This was applauded as a win-win for women, who would receive the new medicalized (thus superior) form of care, and medical students, who would receive a superior medical education — all made possible through the elimination of midwifery.
The official plan in 1910 was to temporarily tolerate midwives who provided care to the very poor — mainly immigrant and minority populations who couldn’t afford to pay the much larger professional fee for an MD-attend birth. However, this forbearance also included a plan to use legal and legislative methods that would eventually eliminate the lawful practice of midwifery in the United States.
In the meantime, leaders in the obstetrical world were busy making arrangements with the Carnegie and Rockefeller foundations and other charitable and philanthropic groups. The obstetrical profession was urging them provide an alternative to midwives by financing clinics that provided free or very low-cost maternity care to poor pregnant women. These women would them be instructed to go to a particular local hospital when they went into labor.
These charitable foundations would then pay the full professional fee of public-spirited physicians who graciously volunteered to cared for these charity cases and attended their hospital births. Of course, the hospitals also appreciated the guaranteed additional business that was part of these arrangements. A few obstetricians with an eye to the future boldly envisioned a time when this private philanthropic function would be taken over state and local governments, and in the interest of public safety, a program for low-income women would reimburse MDs out of taxpayer funds for attending medically-indigent maternity patients.
Having so throughly undermined midwifery as an independent profession, the obstetrical world assumed there would soon be no need for midwives anywhere in the United States and childbirth services would be the sole domain of the obstetrical profession. This goal was easily achieved during by the 1950s. Both the public and medical world celebrated the ‘elevation’ and professionalization of maternity care by physician-surgeons who the mind’s eye provided care in sparkling clean antiseptic hospital wards, while surrounded by smiling faces of happy healthy women holding their adorable new babies.
What was behind the “No Admittance ~ Authorized Personnel Only” sign on double doors to the L&D suite?
What the public did not see was rows of women laboring under the influence of Twilight Sleep who were struggling against the 4-point leather restraints used to keep them from falling out of bed and hurting themselves — the natural result of the hallucinations caused by the drugs they’d been give. They also didn’t see doctors delivering the depressed babies of women who been drugged senseless with narcotics during labor, and now were unconscious under general anesthesia.
No one except L&D nurses such as myself were allowed to present when the doctor performed the typical ‘generous’ episiotomy or listen to the echo of blood fall in a stream like an open facet into the empty stainless-steel bucket 30 inches below the mother’s buttocks. No one but me and the other nurses knew that doctors routinely instructed L&D nurses to provide an extremely brutal and dangerous form of fundal pressure, which meant pushing with one’s entire weight on the top of the mother’s uterus, to thrust the baby down in the mother’s pelvis while the doctor pulled from below with forceps.
After a few hair-rasing minutes of this, the doctor extracted a limp baby with forceps and then handed the respiratorily depressed baby to the nurse to resuscitate. Turning his attention back to the new mother, he reached them his gloved hand and arm up into her uterus to manually remove the placenta.
This private drama ended when the doctor sutured the episiotony incision and finished with what was called “the husband stitch”. Apparently one of the obstetrician’s professional duties at that time was to be sure the husband had no reason later to claim that after the baby was born, “having sex with my wife is like walking into a warm room”. A happy husband was obviously important to the obstetrical profession.
As for the mother, her baby would be sent to newborn nursery so her husband and other family members could enjoy looking at their newborn lay under a warming light for the next 12 hours.
The mother herself would be unconscious or groggy for hours more, while being cared for by nurses the recovery room. Eventually she would rouse enough to ask ‘What did I have?” The nurse would happily inform her that she had a girl (or a boy). Then the groggy mother would fall back into her stupor for another hour or two.