What Happened to Midwifery in America? Part 2

Beware the “Modern” Childbirth

The 19th century began an era of modern childbearing that transformed birthing from a family-centered occurrence to an isolating, anxious experience for laboring mothers. Attending physicians usually discouraged any participation from family and friends. Supporting relatives were considered an irritating interference, hindering the doctor’s ability to make fast work of extracting an infant from its mother’s body. Along with the family and friends of laboring women, midwives were kicked out of the birthing rooms in America. Increasingly, uncomplicated pregnancy and childbirth were considered to be potentially dangerous and pathologic conditions. Following the changes in attitude, particularly by physicians, women were persuaded to give birth in physician-run hospitals. Intervention became the norm and was emphasized as necessary for “childbirth safety”. Middle and upper class women were encouraged to embrace obstetrical propaganda about better and safer deliveries by doctors.

Who remembered to bring the forceps? And the masks?
Austrian National Library

Scientific But Far From Sanitary

“Scientific knowledge”, as it related to normal birthing, was determined to be far superior to the centuries-old, traditional and practical knowledge of midwifery. For women who could afford it, no medical procedures or invasive mechanical intrusions were considered too excessive. Unfortunately, due to the preferences of heavily-influenced expectant mothers, they ultimately became exposed to a devastating epidemic of maternal infections and traumatic injuries which were caused by unclean instruments and the contaminated hands of the doctors wielding them.

Instrumental deliveries in hospitals were mostly devoid of even ordinary cleanliness. Aseptic and sterile practices were not utilized during and after deliveries due to ignorance regarding the existence of bacterial or viral pathogens in the birthing environment. Likewise, antibiotic and antimicrobial treatments had not yet been developed. Many new mothers died of puerperal (birthing-related) infections. Maternal mortality ran rampant in the “skilled” obstetrics wards where the idea of a normal pregnancy and delivery was considered a fallacy.1

New OB Hospitals Escalate Maternal Mortality

Maternal mortality rates in the new OB hospitals became so high that a White House-sponsored public health conference was convened in 1925 to address the problem. Statistics collected from the conference confirmed that women who delivered with midwives were not subject to the devastating morbidity and mortality of women who were delivered in hospitals by obstetricians.

The White House study also concluded that hospitalized women in America had increased incidences of childbirth interventions which resulted in maternal and infant mortality statistics that were significantly higher than those collected in Europe, where midwives were accepted as competent healthcare providers and had the opportunity to practice. Despite the findings of this conference, modern obstetrical medicine prevailed over home-centered midwifery care.*

They could wield the forceps and smoke cigars at the same time!
unsplash-image

Male Physicians Obliterate Midwifery

Incrementally, midwives were banned by male physicians from the wards of obstetrics hospitals. Allopathic medicine (MD educated) became popularized and promoted by wealthy industrialists who interacted socially with medical doctors within the upper echelons of society.

Other specialist health care providers, such as nurses, midwives, homeopathic and botany-based healing practitioners were relegated to caring for “lower classes” of Americans. One bastion of allopathic medicine was the famous Johns Hopkins Hospital. That entity was active in establishing MD-trained doctors as the predominant profession for providing acceptable health care.

Eventually, nurse-midwives were excluded as legitimate providers of “professional” healthcare and were left to attend women living in rural, isolated areas and assisting childbirth in tenements of the inner-city poor. At the turn of the 20th century, American MDs were fighting hard to abolish what was left of American midwifery. In 1920 Dr. Joseph B. DeLee published a famous article titled: “The Prophylactic Forceps Operation”. **

And He Called the Midwives Barbarian. . .

In this article the surgical incision that was to become known as an episiotomy was promoted by male doctors as a preventive procedure to avoid serious perineal tears and prolapse of maternal reproductive organs. Detailed descriptions of the “operation” outlined high points of the procedure, such as the generous use of narcotics, disorienting anesthetic gases, and metal instruments to pull the baby from the womb. In addition, generous cuts, from vagina to rectum, were previewed along with administration of the drug, oxytocin, which was utilized to stanch the inevitable hemorrhaging provoked by the mechanical manipulation of a woman’s uterus, cervix, and pelvic floor soft tissues. Dr. DeLee created video presentations highlighting the use of forceps stating, for the record, that: “It’s not the forceps, but the man behind the forceps, that matters”. In his scholarly papers, Dr. DeLee was emphatic regarding the evils of midwifery, referring to midwives as “relics of barbarism”.***

**Barbarian midwives on their way to a delivery**
**Artem Kniaz**

The Extinction Phase of Midwifery

By 1930, only 15% of births were attended by midwives. In contrast, European and Scandinavian countries were embracing obstetrics for pathological deliveries but were supporting schools for the education of midwives. Dual systems of maternal care were developed where midwives continued to attend uncomplicated, normal births and the obstetric consultants were summoned for complicated, high-risk deliveries. 2

Hospital Birthing Became Popular With Society Women

During the late 1930’s and early 1940’s, American women became particularly attracted to hospital care for childbirth. As a consequence of most women’s understandable fear of pain and death in childbirth, the promise of a safe and pain-free hospital experience became irresistible. By the 1940’s, over half of births took place in hospitals. By 1951, 90% of births in America took place in hospitals with obstetricians. By mid-century, American midwifery was almost completely wiped out.

During the Women’s Movement of the 1960’s and 1970’s, pregnant women began to demand more flexibility in hospital childbirth. However, those who wanted less medical intervention during their childbirth experience were frequently frustrated by lack of cooperation from hospital staff. Hospital nurses, in particular, were reluctant to participate in “un-medicated deliveries”, considering the demands of women desiring a “natural birth” to be radical and unsafe. During this time, cesarean deliveries were common, occurring at increasingly high rates despite a lack of scientific evidence demonstrating that routine surgical interventions had little effectiveness in improving maternal-child health. 3

Why Is It Still Such a Fight?

Over time, nurse-midwifery practice was, reluctantly, allowed to return to hospitals and clinics. This did not occur without a fight. In many ways, it is still a fight. The tenacity and conviction of dedicated CNMs forged the way for so many practicing today. Unfortunately, negative attitudes and overt condemnation from physicians created a difficult atmosphere within which to practice. Labor and delivery nurses, prejudiced against CNM care, felt justified in refusing to care for nurse-midwifery patients, claiming that their participation made them vulnerable to lawsuits. There was no basis in fact for these claims, but it was a convenient excuse to avoid caring for difficult midwifery patients. Hospital administrations supported these behaviors which made the working environment even more stressful.

Against all odds, nurse-midwifery prevails, although battle-weary. Professional midwifery practice has modestly proliferated over time, but still remains in jeopardy due to the persistence of uninformed and hostile attitudes in hospital administration and from medical, nursing, administrative staff, and liability carriers. Equally discouraging, corporate healthcare is gnawing away at nurse-midwifery, closing practices and utilizing CNM’s only if it serves financial interests. Additional challenges to practice include the threat of legal liability, high malpractice insurance costs, role-confusion, collegial disdain, and decreasing opportunities to practice while remaining true to a midwifery model of care.

1. Suarez, SH. Midwifery Is Not The Practice Of Medicine. 1992. Yale Journnal of Law and Feminism. 5(2):6 page 327. Available at: https://digitalcommons.law.yale.edu/yilf/Vol 5/Iss2.

2. These systems of care exist today in Europe, Scandinavia, and around the world where midwifery units attend to uncomplicated pregnancies and deliveries. Depending on acuity, when laboring women develop complications, they are transferred a short distance to the consultant units for care. Even in the higher risk units, both midwives and physicians can participate together in caring for patients.

3. Brodsky, supra note 13, article 6.

* Judy Barrett Litoff; Forgotten Women: American Midwives at the Turn of the Century. The Historian. Vol. 40. No. 2 (February 1978), pp. 235-251.

** The Prophylactic Forceps Operation (1920), Joseph Bolivar DeLee. American Gynecological Society (1920): 66-83.

*** See above

https://www.midwivesontrial.com

Significance For Practice

Relevance:

Understanding the evolution of midwifery practice and gaining perspective on how societal attitudes have evolved (or not) regarding midwifery legitimacy is essential to establishing and understanding your role and responsibilities in maternal healthcare. In the context of where nurse-midwifery has been, and is currently heading, maintaining their identities in corporate healthcare has become difficult. CNMs/CMs are struggling to preserve a distinct role in modern maternity care. Protecting midwifery identity in the midst of rapidly evolving corporate needs for qualified maternity care providers will be an ongoing challenge for newly-graduated (and vintage) CNMs/CMs.

Situation:

Professional distrust of midwifery by colleagues/hospitals remains pervasive yet CNMs/CMs are being used as physician extenders and surrogates to fill provider vacancies (particularly for night shifts) in acute care settings. Maintaining true to a midwifery model of care and identity as a midwife is increasingly difficult in hospital practice. Midwives are functioning like physicians in many acute situations but are not compensated nor supported appropriately. Hospital financial interests are frequently jeopardizing safe care.

Vulnerability:

Role uncertainty and confusion with decreasing opportunities to practice utilizing a midwifery model of care. Confusion regarding your role (and potential liability risk) in acute care situations.

Considerations:

It is important to define your role and responsibilities in every care situation. It may be necessary for you to decide how you want to identify; as a midwife or physician-extender. Find ways, in acute non-midwife care situations, to provide any version of midwifery-centered care, when possible. It is entirely appropriate to maintain the heart and patience of a midwife, even while initially managing or participating in a high-risk delivery. Take the time to imagine ways that you can still apply a midwifery model of care while safely and competently functioning in the midst of less-than-normal OB situations.

What Happened to Midwifery in America? Part 2

Who remembered to bring the forceps? And the masks?

Myth of the Ordinary Midwife Part 2

What Happened to Midwifery in America? Part 1