MIDWIVES AND MEDICAL MEN

12 May

Of course, puerperal fever was not always an epidemic disease and childbirth  did not always fall within the province of medical men. While women were almost  universally excluded from the medical profession, the province of midwifery was once exclusively theirs. Until very recent times, childbirth  was considered a natural, rather  than  a medical event. When labor began, a woman remained  at home and sent for her female friends,  relatives,  and  a midwife.  This  ‘‘social childbirth’’  provided  a support  system in which women comforted  the laboring  woman, shared experience   and   advice,   provided   witnesses   against   accusations   of infanticide,  and helped the new mother  through  the lying-in period.

Throughout  much   of   European  history,   religious   authorities exerted considerable  influence over the selection of midwives; character and piety were essential criteria for obtaining  approval.  Midwives were forbidden  to perform  abortions or conceal a birth.  They were expected to make the mothers of illegitimate infants reveal the name of the father. If an infant seemed likely to die before proper  baptism,  a qualified mid- wife could  perform  an  emergency  baptism.  Should  the  mother  die in labor,  the midwife might attempt  baptism  in utero  or cesarean section. According  to  the Dominican inquisitors  Heinrich  Kra¨ mer and  Jakob Sprenger, the authors  of the infamous  Malleus Maleficarum (The Ham- mer of Witches, 1486), midwives were among the most pernicious  of all witches. Midwives were accused of inducing  miscarriages  and  offering newborn  infants to Satan.  The products  of miscarriages  and abortions, stillborn infants, the umbilical cord, and the afterbirth (placenta) played a notorious role in the pharmacology of witchcraft. Given the midwife’s low status and wretched fees, the temptation to engage in magic, sell for- bidden materials,  or accept bribes for family planning through  abortion

Midwives Attending a Delivery

or infanticide, must have been overwhelming. While there were few prosecutions for the crime of witchcraft in England after 1680, the witchcraft statutes were not repealed until 1736 and there is evidence that the belief in witches persisted into the late eighteenth century. Because of the biblical curse on Eve, midwives were forbidden to use drugs or magical practices to ease the pain of childbirth. Nevertheless, midwives trafficked in charms, amulets, and drugs said to relieve pain and facilitate labor. When discovered, the patient and the midwife might face heavy penalties. As women became increasingly disadvantaged in terms of legal opportunities to study and practice medicine, those women who had served as healers were extirpated from historical memory. One example of this process is the treatment of Trotula of Salerno in histories of medi- eval medicine. There has been considerable disagreement as to whether Trotula was a professor at the University of Salerno during the twelfth century and the author of major treatises on obstetrics and gynecology, or a mythical, and somewhat ludicrous figure sometimes referred to as Dame Trots. Simplified translations of gynecological texts attributed to Trotula were treasured by generations of women. The English Trotula, for example, contains complex and bizarre remedies, advice about con- ception, pregnancy, childbirth, ‘‘wind in the uterus’’ and other female problems. For readers who were skeptical about certain prescriptions, the author helpfully suggested testing them on chickens or roosters. By the middle of the fifteenth century, secular authorities were beginning to displace the church in regulating the practice of midwifery. When labor did not proceed normally, the midwife, who was prohibited by law from using surgical instruments, was required to send for a doc- tor. Although the penalty for disobedience might be death, midwives apparently adapted common tools to suit their needs, as indicated by accusations that midwives used hooks, needles, spoons, and knives in difficult deliveries. Many midwives were probably illiterate or too poor to buy books, but medical men objected to the publication of midwifery texts in the vernacular. The earliest printed textbook for midwives, Eucharius Ro¨ sslin’s (d. 1526) Garden of Roses for Pregnant Women and Midwives (1513), was still in use in the 1730s. The German text, which was mainly a compilation of Greek and Latin works, included 20 illustrations. An English translation published in 1540 was entitled The Byrth of Mankynde. A few women were able to emerge from the largely anonymous ranks of female practitioners and issue strong calls for improvements in the training and status of midwives. In France, Louise Bourgeois (1563–1636) gained fame as midwife to the French court. In writings addressed to her daughter, Bourgeois described the difficulties of a career as a midwife. Patients took the midwife for granted when childbirth was normal, but blamed her for complications and still- births. Elizabeth Cellier, a seventeenth-century London midwife, was known to contemporaries as an ‘‘ingenious, and energetic woman,’’ but nineteenth-century male obstetricians called her efforts to raise the status of midwives ‘‘unscrupulous.’’ In a petition submitted to King James II in 1687, Cellier argued that unskilled birth attendants were respon- sible for the deaths of many infants and mothers. To reduce infant and maternal mortality and improve the status of midwives, Cellier pro- posed the establishment of a College of Midwives and a royal hospital. Cellier hoped the king would support and fund her proposal, but the College of Physicians easily suppressed this scheme. Despite the notor- iety associated with Cellier’s trials for high treason and libel, little is known about her life. After she was acquitted of involvement in the ‘‘Meal-Tub Plot’’ of 1680, she published an account of the affair, under the title Malice Defeated; or a brief relation of the Accusation and Deliv- erance of Elizabeth Cellier, which led to a trial for libel. Found guilty of libel, Cellier was ordered to pay a fine and stand in the pillory. Cellier’s willingness to petition the king and her ability to write and debate her critics demonstrate that some seventeenth-century midwives were liter- ate and active in public life. Indeed, studies of the hundreds of women who practiced midwifery at the time indicate that many were well trained, successful, and respected. Despite evidence that eighteenth-century doctors were displacing female midwives as birth attendants, at least for wealthy women, Mar- guerite Le Boursier du Coudray (1715–1794), the ‘‘king’s midwife,’’ enjoyed a long and successful career. In 1740, du Coudray was certified to practice midwifery in Paris after passing an examination administered by a panel of royal surgeons and experienced midwives. Her successful practice and political skills resulted in her appointment as the king’s midwife. In this capacity, she traveled throughout France to teach mid- wives and surgeons about the latest methods of delivery. The ingenious du Coudray designed an elaborate ‘‘teaching machine’’ that consisted of a life-sized model of the female pelvis with a fetus, placenta, and umbili- cal cord and published an illustrated textbook on the art of midwifery. A survey conducted in 1786 suggests that du Coudray or her assistants trained at least half of the midwives, surgeons, and doctors who were delivering babies at the time. Soranus of Ephesus (98–138) was considered an authority on obstetrics and gynecology, but the birth attendant he described in the Gynecology was a midwife—literate, familiar with medical theory, free from superstition, strong, sober, respectable, dexterous, and female. Although physicians from Hippocrates to William Harvey were inter- ested in obstetrics and gynecology, they took it for granted that the practice of midwifery belonged to women. Even in the seventeenth cen- tury, the man-midwife was a controversial, menacing, yet somewhat ridiculous figure. Doctors or surgeons were only called for in cases of difficult or obstructed labor. When the man-midwife appeared, the death of the mother or the infant was the most likely outcome. As doc- tors became more successful at managing difficult births, women were more willing to call on them before complications occurred. By the eighteenth century, wealthy women were increasingly likely to choose male attendants, hoping for a safer delivery. Doctors who used obstetrical instruments began to replace the surgeons who had extracted dead fetuses and the midwives who were not allowed to use surgical instruments. Ancient misconceptions about the female reproductive system were closely linked to medical theories about conception, gestation, sex deter- mination, and childbirth. Of special significance in the management of birth was the idea that the fetus, rather than the mother, was the active participant in the process. Since the laboring woman was regarded as the obstacle, the doctor’s task was to employ whatever tools were neces- sary to assist the poor little prisoner in its struggle to escape from the womb. Nevertheless, as medical men challenged midwives for control of childbirth, their claims were heavily based on their alleged possession of superior knowledge of female reproductive anatomy and physiology. Renaissance anatomists had certainly rejected many myths about the human reproductive system, such as the ancient Greek description of the uterus as a mobile, restless, two-chambered organ with an innate hunger for childbearing. Still, even in the early twentieth century, there was considerable controversy over the morphology of the uterus, the function of the cervix, and the mechanism of labor. A good example of the way in which writers create rather than recreate the past can be found in two books written by James Hobson Aveling (1828–1892), Physician to the Chelsea Hospital for Women and Examiner of Midwives for the Obstetrical Society of London. Aveling’s hagiography, The Chamberlens and the Midwifery Forceps (1882), was written to demonstrate the great contributions of medical men to midwifery. In contrast, the stated purpose of Aveling’s English Midwives: Their History and Prospects (1872) was to call attention to female midwives and show the misery and damage that had resulted from their ignorance. Aveling used a picture of Elizabeth Cellier at the pillory as the frontispiece of his history of midwives, as if her crime had been medical malpractice rather than libel of a political nature. Trying to explain just how low the midwife’s status was, Aveling noted that a midwife might even be called to attend cows that were experi- encing a difficult delivery. In impoverished rural households, however, where a cow might be considered more valuable than a wife, such a request was probably not taken as an insult. Aveling claimed that William Harvey had rescued English mid- wifery from its place as the most despised part of the medical profession. But it would be more accurate to say that it was a monopoly on the obstetrical forceps and other surgical implements, as well as large claims of specialized professional knowledge, that was responsible for male domination of the field rather than Harvey’s remarkable studies of embryology. The origins of the obstetrical forceps are obscure, although the instrument seems simple enough in form and function. All that is known with certainty is that the ‘‘hands of iron’’ evolved from instru- ments of death. Before surgeons adopted the obstetrical forceps, they could do little more than kill and extract an impacted fetus with knives, hooks, perforators, and lithotomy forceps, or attempt cesarean section on a moribund woman. By the early eighteenth century, medical men had several versions of the obstetrical forceps, with which they could deliver a live, if somewhat squashed baby. The original version of the instrument, however, had been invented at least one hundred years before by a member of the Chamberlen family. Between 1600 and 1728, while famously boasting that their skills in managing difficult labors far exceeded those of any member of the Royal College of Physicians, four generations of Chamberlens enjoyed a lucrative midwifery practice. Just which of the Chamberlens invented the obstetrical forceps is uncertain, because of the family’s obsessive secrecy and strange penchant for naming almost all sons Peter or Hugh. In 1598, Peter Chamberlen the Elder (1560–1631) was inducted into the guild of barber-surgeons. Peter the Elder was probably the inventor of the first practical obstetrical forceps. Using his secret instrument, Peter the Elder was able to deliver babies who would otherwise die. Although he was only a barber- surgeon, Peter the Elder had royal patrons, including Queen Anne, wife of King James I. The Chamberlens claimed that it was Peter’s remark- ably skill in midwifery that led to a series of prosecutions by the Royal College of Physicians. In addition to fines and censures, Peter the Elder was sent to Newgate Prison for the crime of practicing medicine without a license. Like his older brother Peter the Elder, Peter Chamberlen the Younger (1572–1626) was a barber-surgeon who specialized in mid- wifery and feuded with the Royal College of Physicians. Hoping to ter- minate a long series of prosecutions by elite London physicians, Peter the Younger attempted to join the College. He presented himself for examination in 1610, but apparently failed to satisfy the examiners that he was sufficiently learned in medicine. Members of the College, includ- ing the eminent Robert Fludd (1574–1637), had previously accused Peter the Younger of insulting the College. Dissatisfied patients had also complained that Peter had taken large fees, promised complete cures, and then gave them medicines that made them worse. In 1616, Peter the Younger became involved in efforts to organize an official corpor- ation for the midwives of London. The College of Physicians rejected the petition. In 1634, Chamberlen’s eldest son, Peter Chamberlen Jr. (1601–1683) revived the proposal, but it was again rejected. Peter Chamberlen Jr., studied medicine at several prestigious Italian medical schools and became the first member of the family to obtain a bona fide medical degree. In 1628, Doctor Peter Chamberlen became a member of the Royal College of Physicians, the prestigious organization that had persecuted and harassed his father and uncle. Doctor Peter was physician-in-ordinary to three Kings and Queens of England and several foreign princes. Like the previous Peters, the first Doctor Chamberlen boasted of his success as an obstetrician and quarreled with the College of Physicians. Three of Doctor Peter Chamberlen’s sons—Hugh Senior, Paul, and John—became obstetricians and continued to profit handsomely from the family monopoly. Doctor Hugh Chamberlen (1630–1720) served as midwife to Catherine, wife of Charles II. In the preface to his translation of a French treatise on midwifery, Hugh acknowledged that women were invariably afraid of seeing a doctor enter the lying- in room, because they were sure that when ‘‘the man’’ came, mother or child would die. But, he revealed, this need not be the case. The Chamberlens had, ‘‘by God’s Blessing’’ and their own genius and indus- try, discovered a way of safely delivering the infants of women in difficult cases where any other practitioner ‘‘must endanger, if not destroy one or both with Hooks.’’ Apologizing for not sharing the secret of his success, Hugh explained that he could not do so without financial injury to his family. Eventually, however, he betrayed the family secret by offering to sell the instrument. In 1818, a collection of obstetrical instruments was discovered in a hidden compartment in a house once owned by the Chamberlens. The original obstetrical forceps had separable, curved, and fenestrated blades. After the blades had been inserted into the birth canal, one at a time, they were positioned around the head of the infant. The crossed branches were then joined and fastened with a rivet or thong, so that the doctor could grasp the instrument and exert traction. The instrument looked somewhat like salad tongs grasping a head of lettuce. In his hagiography of the Chamberlens, Aveling made the startling claim that among the forceps discovered in Dr. Peter’s house was ‘‘doubtless the first midwifery forceps constructed by the Chamberlens, and from which sprung all the various forms now in use.’’ How these instruments could have sprung from such a well-kept secret is something of a mystery. In any case, by the mid-eighteenth century, several versions of the obstet- rical forceps had been independently invented. Over the years, many variations on the basic instrument were introduced—some trivial, some futile, and some dangerous. Perforators and hooks on the handles of the instrument were employed when a forceps delivery was unsuccessful. Not all doctors were convinced that the instrument was invariably a blessing to women in labor. The great English surgeon, obstetrician, and anatomist William Hunter (1718–1783), for example, cautioned practitioners that ‘‘Where they save one, they murder twenty.’’ An early warning of the threat medical men would pose to mid- wives and their patients was issued by the English midwife, Jane Sharp, author of The Midwife’s Book; or, The Whole Art of Midwifery Discov- ered (1671). Sharp’s text, the first midwifery manual written by a British woman, was an accessible, practical guide for midwives, based on her experience and available medical information about the female body and its reproductive functions. The text included descriptions of the female and male ‘‘generative parts,’’ discussions of conception, sterility, labor, miscarriage, illnesses and diseases related to pregnancy, postpar- tum care, wet nurses, the newborn infant, and common childhood dis- eases. Sharp argued that female midwives were sanctioned by the Bible, whereas male midwives were not, and that women should place greater

Cesarean Section

Cesarean Section.
reliance on God than the College of Physicians. Although Sharp acknowledged that infant and maternal mortality rates were distress- ingly high, she refused to let midwives bear all the blame. Emphasizing the poverty and misery endured by the majority of women, she insisted that poor women needed meat more than they needed the services of physicians and surgeons. Poorly trained midwives and surgeons contributed to infant and maternal mortality, but malnutrition, crowded and unsanitary housing, contaminated food and water, bad air, and occupational hazards de- served equal honors, as demonstrated by the work of the leaders of the nineteenth-century sanitary reform movement. Although infant mor- tality averaged about 150 per 1,000 live births for England as a whole, in working class areas the rate was much higher. Where mothers were employed and drugs were used as ‘‘babysitters,’’ infant mortality rates soared to 200–260 per 1,000 live births. Apothecaries sold hundreds of pounds of opium per year in the form of pills, elixirs, and soothing cordials. While mothers worked in fields or factories, their tranquilized babies were left at home to die of drugs, dysentery, and malnutrition. Eighteenth-century moralists and journalists found the man-midwife controversy a wonderful source of salacious and titillating stories. Social critics warned that French dances, French novels, and male mid- wifery would lead to the complete corruption of female virtue, social chaos, and the end of civilization. The man-midwife was also the object of scorn within the medical profession, where all forms of specialization were regarded with suspicion. The College of Physicians was reluctant to allow obstetricians the rights and privileges of membership, because midwifery was a manual operation, foreign to the ways of learned gen- tlemen who should not stoop to participating in the ‘‘humiliating events of parturition.’’ But to keep the spoils within the family, leaders of the College of Surgeons suggested that midwifery should be conducted by the wives, widows, and daughters of surgeons and apothecaries. Critics charged the man-midwife with deliberately exaggerating the dangers of childbirth in order to turn a natural event into a surgical pro- cess for self-serving motives. Doctors were also accused of misusing instruments to save time and justify large fees. According to one English midwife, the man-midwife hid his mistakes in a cloud of scientific jargon so that confused patients thanked the man who had killed the infant and maimed the mother. Obstetricians cynically shared tricks for impressing the patient and avoiding blame. For example, if the doctor left during the early stages of labor, he should poke the patient intravaginally and tell her he was doing something to help the progress of labor. Thus, even if he was not present when the child was born, he could claim the credit if all went well, and blame the nurse for any problems. Some doctors admitted that factors other than the sex of the birth attendant might determine the outcome of labor. Dr. Charles White (1728–1813) of Manchester, for example, noted that sick, half-starved, impoverished, rural women, served only by the worst sort of midwives might actually have a lower maternal mortality rate than city women delivered in lying-in hospitals, or wealthy women attended by male doc- tors. Critics of female midwives argued that women were totally unable to master scientific knowledge or use medical instruments. Since prob- lems could develop suddenly, even in apparently normal labors, all cases should be attended by male practitioners. Many doctors were willing to accept a class of midwives who would relieve them of unprofitable cases, but they would not tolerate women who might offer real competition. Members of the Obstetrical Society saw a clear division between the role of the midwife and that of the obstetrician. Midwives were suitable for poor women, because they were less delicate than rich women and, therefore, less in need of sophisticated medical assistance at childbirth. Midwives should be restricted to ‘‘the hard, tedious, ill-paid work appropriate for women’’ while medical men maintained a ‘‘manly and dignified position’’ in ser- vice to wealthy clients. Midwives were supposed to call for a doctor when confronted by abnormal labor, but doctors might refuse to see a patient who had chosen to use a midwife. Even in notorious cases where women died because obstetricians would not respond to a mid- wife’s appeal for assistance, many doctors argued that such fatalities would teach the improvident to mend their ways, save their money, and call a doctor first. When potential patients realized that doctors would not ‘‘cover’’ for midwives, these archaic female competitors would disappear. The outcome of the rivalry between midwives and medical men was already obvious by the end of the nineteenth century. The promise of total victory was apparent in Aveling’s claim that the sordid history of the ignorant and incompetent midwife was drawing to a close. Never- theless, the triumph of the medical man in the nineteenth century is an enigma. Certainly, science had not yet entered the lying-in chamber. The transition from midwifery to obstetrics occurred at a time when intervention was often performed by rough, inexperienced, surgically- oriented practitioners, still concerned with strength and speed, uninhibi- ted by considerations of asepsis. Moreover, the transition occurred in a period obsessed with female modesty. The proper Victorian lady was expected to prefer death to a discussion of ‘‘female complaints’’ with a male physician. Women entering the medical profession in the late nine- teenth century also tended to disapprove of traditional midwives. Strug- gling for a place in the medical community, they generally accepted Victorian conventions of female modesty and argued that female doctors were a better choice for childbirth than midwives or male doctors. Paradoxically, the most prudish societies of all were those that most completely accepted the new male-dominated obstetrics. It has been argued that the medicalization of birth reflected a deeper concern for the welfare of women. Alternatively, the paradox can be explained as a reflection of hostility towards women which generated a desire to punish them for their sexuality by the ultimate degradation: taking away their female support system and substituting the control of the male doctor who would transform the dangerous, unpredictable process of childbirth into a routine surgical process. Certainly, the argument that birth was a pathological process, and that perhaps nature deliberately intended for women to be ‘‘used up in the process of reproduction, in a manner analogous to that of salmon,’’ suggests a deep-seated contempt for women, or at least a lack of sympathy. As the role of the hospital expanded in the eighteenth and nine- teenth centuries, physicians in the major cities were able to gain the clinical experience that made it possible for the ‘‘hands of iron’’ to emerge as the ‘‘imperishable symbol and weapon’’ with which the bat- tles between traditional female-centered births and the medicalization of birth would be fought. With the introduction of obstetrical anesthesia in the 1850s, the physician could add the promise of pain-free labor to his monopoly on obstetrical instruments. Forceps and anesthesia could make childbirth more rapid and less painful, but the resultant burden of injury and infection was a heavy price for women to pay. Critics warned that when the mother was under anesthesia, the forceps could be used brusquely and unnecessarily, causing profound damage to mother and infant. Often the damage was done simply because the doctor had not troubled himself to be sure that maternal tissues were not trapped within the locking mechanism of the forceps. On the other hand, doctors who took the precaution of passing a finger around the locking mechanism—a finger ungloved and perhaps unwashed—also endan- gered the patient. Although the poor and desperate women who served as clinical material in the hospitals of the nineteenth century had little choice in birth attendants, wealthy women increasingly chose physician-attended home delivery in hopes of safer and less painful deliveries. During the mid-twentieth century, childbirth moved out of the sphere of women’s domestic culture and into the hospital. To improve the status of obstet- rics as an area of specialization, Joseph B. DeLee (1869–1942) and other leading obstetricians considered it essential to eliminate competition from general practitioners as well as midwives. According to DeLee, childbirth was a surgical procedure that should be managed by an obste- trician in a hospital operating room where forceps deliveries and episio- tomies were routine. The Chicago Maternity Center, founded by DeLee, provided ‘‘clinical material’’ for an intensive course in obstetrics where students from Wisconsin, Marquette, and Northwestern University were taught DeLee’s principles of scientific obstetrics. The trend towards hospital delivery had been accelerating since the 1920s. Before 1938, in the United States, half of all babies were still born at home; by 1955, about 95 percent of all births took place in hospitals where the laboring woman found herself ‘‘alone among strangers.’’ This transition has been called the most significant change in the history of childbirth, but it occurred before the medicalized hospital birth had actually become statistically safer than home births. Nevertheless, women chose hospital delivery with the expectation that the hospital offered expertise, new technology, freedom from pain, and increased safety for both mother and infant. Ever since medical men gained a monopoly over the ‘‘hands of iron’’ and the ‘‘potions of oblivion,’’ the midwife has been an endangered species. Unlike chiropractors, optometrists, podiatrists, and dentists, the midwife never had a chance at the title ‘‘doctor.’’ In the 1960s and 1970s, interest in natural approaches to health care and the Woman’s Rights Movement led to calls for a return to ‘‘woman-centered childbirth,’’ but the trend towards medicalization of birth had become so powerful that in the 1980s more than 25 percent of all babies born in some Amer- ican hospitals were brought into the world by cesarean section. In this context, the history of puerperal fever and midwifery are clearly only part of a complex transformation that encompassed changes in medical institutions, professional roles, social expectations, and beliefs about the nature of woman. The man-midwife entered the female-dominated world of social childbirth as a lowly surgeon, transformed childbirth into a surgical event in the physician-dominated world of the hospital, and created highly valued professional roles for obstetricians and gynecologists. The increased use of anesthesia—ether and chloroform in the second half of the nineteenth century and ‘‘Twilight Sleep,’’ a combination of mor- phine and scopolamine, in the early decades of the twentieth century—also increased the status of the obstetrician. Women learned that the benefits of painless childbirth were only available in a hospital setting with a trained obstetrician. Twilight Sleep was often combined with the ‘‘prophylactic forceps operation,’’ episiotomy, and other routine surgical interventions. Episiotomy was promoted as part of obstetric practice in the 1920s, sup- posedly as a means of preventing serious lacerations of the perineum dur- ing childbirth, but probably its main effect was to make it easier to insert forceps and expedite delivery. By the 1980s, however, researchers began to realize that the risks associated with episiotomy were significantly greater than the alleged benefits. Other forms of surgery on the female repro- ductive organs were also quite common in the late nineteenth and early twentieth centuries. Such surgery included what was called ‘‘normal ovari- otomy’’ because it was carried out on normal healthy ovaries. Gynecolo- gists argued that this operation could correct the behavior of women exhibiting sign of insanity, neurosis, mental instability, menstrual irregula- rities, and so forth. Clitoridectomy was done for similar reasons. Critics of the ‘‘over medicalization of modern life’’ warn about the dangers of treating normal female functions, including pregnancy and menopause, as pathological states. For example, since the 1960s, some gynecologists have argued that menopause is an estrogen-deficiency disease and that estrogen replacement therapy was needed to prevent defeminization, hypertension, high cholesterol, osteoporosis, arthritis, and serious emotional disturbances. Despite claims that hormone replacement therapy (HRT) was completely safe, by 1975, researchers had evidence of a relationship between postmenopausal estrogen ther- apy and endometrial cancer. Other reports of damage caused by medical devices and prescription drugs furthered feminist criticism about medi- cal interventions in women. The abuse of diethylstilbestrol (DES), a synthetic estrogen first produced in 1938, demonstrated that the medi- calization of pregnancy and childbirth could also be dangerous to the next generation. Diethylstilbestrol was prescribed for menopause, dia- betes, amenorrhea, dysmenorrhea, genital underdevelopment, infertility, morning sickness, toxemia, suppression of lactation, and to prevent spontaneous abortion. Many obstetricians considered DES part of the routine management of pregnancy. In some clinics that were engaged in tests of DES, pregnant women were not told that the ‘‘vitamin pills’’ they were given contained an experimental drug. In 1970, when a rare form of malignant vaginal cancer (clear cell adenocarcinoma) in young women was linked to intrauterine exposure to DES, the FDA ruled that DES was ‘‘contraindicated for use in the prevention of miscarriages.’’ The question of whether DES actually prevented miscarriage remains controversial, but researchers found sig- nificant evidence that the synthetic hormone is embryopathic, terato- genic, and carcinogenic. Neonatologists noted that DES was only one of many ineffectual and dangerous treatments that were supposed to improve pregnancies or help newborns. For example, thalidomide, the most notorious teratogenic agent of the twentieth century, was prescribed as a remedy for morning sickness during pregnancy and as a sleeping aid. In many parts of the world, midwives continued to have a major role in caring for pregnant women and delivering babies, but efforts to improve the status of midwifery in the United States were generally unsuccessful. In the interests of public health, some American reformers attempted to replace traditional direct-entry midwives with registered nurses who had taken advanced training in midwifery. The Frontier Nursing Service (FNS), initiated by Mary Breckinridge (1881–1965) in 1925, provided a demonstration of the value of nurse-midwifery, as well as the ability of the American medical community to suppress such pro- grams. Breckinridge became interested in midwifery training programs while serving as a volunteer nurse in Europe. As part of her plan to bring nurse-midwifery to impoverished areas in the South, she studied public health nursing at Columbia Teachers’ College and midwifery at hospitals in England and Scotland. Women in the Kentucky mountain region selected for the demonstration program were usually attended by midwives who learned the art from other midwives. Doctors, if avail- able, charged at least ten times as much as ‘‘granny’’ midwives and expected cash rather than payment in-kind. Frontier Nursing Service nurse-midwives provided prenatal care, administered inoculations for typhoid, diphtheria, and smallpox, and treatments for parasitic infections. Although most of their patients lived in poverty-stricken homes, accessible only by horseback, the FNS achieved mortality rates well below those of the general population of Kentucky and the United States as a whole. Although the FNS was largely successful in fulfilling its goals, it did not establish an auto- nomous professional role for nurse-midwifery in the United States. Neither did the any of the other midwifery training programs in rural or urban America. Nevertheless, nurse-midwifery did not entirely disappear. The American College of Nurse-Midwives was founded in 1955 to represent certified nurse-midwives, that is, birth-attendants educated in both nurs- ing and midwifery. Even though certified nurse-midwives are trained to care for healthy women and newborns, they can only practice legally if they are affiliated with a physician. The American College of Obstetri- cians and Gynecologists adopted the policy that cooperation between doctors, nurse-midwives, and other health personnel was possible, if all concerned acted within ‘‘medically directed teams.’’ Although statistical studies repeatedly demonstrated that when nurse-midwives care for pregnant women, there are fewer premature and underweight babies, the medical community remained indifferent or hostile to nurse- midwives. The American Nurses’ Association and the National League for Nursing were also ambiguous about nurse-midwifery. The Midwives’ Alliance of North America, which was founded in 1982, took the position that nursing was not a necessary prerequisite for midwifery. Interest in midwifery began to grow again in the 1970s among women who wanted to avoid aggressive medical techniques like induced labor, epidural blocks, episiotomies, and cesarean sections. Women who were troubled by the impersonality and medicalization that typified hos- pital births began to see midwife-attended home births as a possible alternative. By 2000, every state allowed certified nurse-midwives to practice, however, state laws concerning lay-midwives and home births vary considerably. According to the National Center for Health Statistics, in 1976, certified nurse-midwives attended just one percent of births in America. In 2002, certified nurse-midwives attended almost eight percent of births, but midwifery was in decline by 2004. In New York City, certified nurse-midwives attended about 12 percent of births in 1997, but by 2002, that had fallen to 9.7 percent, according to the City’s Department of Health and Mental Hygiene. Midwives, doctors, hospital executives, and patients generally attribute the declin- ing use of midwives to insurance issues and the threat of lawsuits. Malpractice insurance premiums increased more steeply for midwives than for obstetricians. Only two of the four freestanding birthing centers run by midwives in New York City in 2002 were still in business the next year. Hospitals that had established birthing centers staffed by midwives to attract patients limited the work of midwives by classifying more patients as ‘‘high risk.’’ Even in the twenty-first century, where women’s access to medical care and education is restricted, maternal and infant mortality may approach premodern levels. Studies of Afghanistan revealed remarkably high rates of both infant and maternal mortality. Millions of women across rural Afghanistan live in a constant cycle of pregnancy and birth through most of their adult lives with little or no medical care. A study conducted in 2001 by the World Health Organization estimated that there were more than two thousand maternal deaths per one hundred thousand live births. Babies whose mothers die in childbirth have only a one in four chance of surviving to their first birthday. Almost half of the deaths of Afghan women of childbearing age are caused by compli- cations during pregnancy, or by childbirth itself. Researchers suggested that almost 90 percent of the maternal deaths could have been prevented with better medical care.

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