The 20th Century Coup of The American Childbirth Industry
During the second weekend of November in 1915, hundreds of medical professionals entered the Bellevue Stratford Hotel in Philadelphia. This was a moment of change—progressivism amidst the Bellevue Stratford’s décor of Gilded Age opulence. Since the mid-18th century, doctors had been rising in stature as the occupation transformed from unregulated prescribing and drawing blood to an organized institution.
By 1915, physicians were formidable, respected, and increasingly wealthy; conferences had also become key gatherings for the leading men in the field. The physicians were in town for the Sixth Annual Meeting of the American Association for Study and Prevention of Infant Mortality. The U.S.’s national infant mortality rate was then 99.9 per 1,000, and on the annual meeting’s agenda was a presentation from one of the leading obstetricians at the time, Dr. Joseph DeLee.
DeLee had a primitive opinion of childbirth. He often wondered if nature intended for women to “be used up in the process of reproduction, in a manner analogous to that of salmon, which dies after spawning.” The possibilities of prolapse and laceration fell under the umbrella of the evils of birth and could only be remedied through systematic and surgical practices.
On that fall day in 1915, DeLee spoke to the crowd of physicians about his theories on ideal obstetrics, an ideology that came into direct contrast with midwives. DeLee knew that. “I am fundamentally opposed to any measure designed to perpetuate the midwife,” he boldly said in his opening statement. To DeLee, the midwife was a “relic of barbarism.” He was the premiere obstetrician of this era and saw no place for them in modern obstetrics.
The medicalization of childbirth of this era at first might appear to be a step towards a prioritization of women’s health, but in many ways, it demonstrated the gaps in knowledge that are born when female tradition is overruled by male ego. Midwives, through generations of experience, were known to treat complications and discomfort of birthing mothers through herbal remedies and effective labor postures. These techniques, though scientific in practice, would be overruled by the male-dominated medical establishment as a “a drag upon our science and our art.”
“The medicalization of childbirth of this era at first might appear to be a step towards a prioritization of women’s health, but in many ways, it demonstrated the gaps in knowledge that are born when female tradition is overruled by male ego.”
Until the 19th century, childbirth was a social ritual, with a midwife commanding the birthing environment. Midwife manuals in the U.S., which first began circulating in the 17th century, outlined anatomy, potential diseases, treatments, and even introspections of female sexuality. The midwife model of practice minimized interference in the birth process, letting nature act, though midwives were prepared to adapt to situations such as the baby being in a breech position.
The growing prevalence of the American Medical Association in the latter half of the 18th century was transforming the U.S.’s public health infrastructure and standardizing physician practices. This medical transformation also laid the foundation for changing standards in childbirth. Terms like gynecology and obstetrics emerged as part of a medical vocabulary (ironically, obstetrics comes from the Latin word obstetricus, which meant pertaining to a midwife), and professional physician groups catered to different specializations. While obstetricians were becoming a nationally organized network, midwives worked locally and often independently.
The American Association for Study and Prevention of Infant Mortality’s 1915 meeting was all but a declaration of war against midwives; it set a goal of erasure that would essentially be met over the next 20 years. In the year of DeLee’s fervent speech, midwives in the U.S. attended 40 percent of all births; by 1935 they only attended 10.7 percent. The interventionist approach of early-20th century doctors triumphed, imparting a legacy of childbirth that is still felt in today’s modern hospitals and cultural portrayals.
The changing standards of childbirth did not necessarily improve outcomes though. Medicine had drastically transformed throughout the 19th and 20th century, but standards of sterilizing equipment were still in their infancy. Puerperal fever, a bacterial infection in reproductive organs, was the leading cause of maternal mortality in the early 20th century, and as doctors glided through hospitals attending to different patients, expectant mothers were more likely to be exposed to pathogens that could lead to infection. Interventionist methods further exposed mothers as physicians used forceps, a tong-like tool, to pull babies out while still inside their mother’s belly.
Not all medical professionals supported this shift in reproductive care. Several doctors of the era used birthing statistics to observe that many obstetricians used riskier procedures with no improvement in maternal and infant mortality outcomes, and in some cases with even higher rates. When physicians in New York City studied cases of puerperal fever from 1930-32, they noted the overuse of anesthesia. “Clearly a reduction in mortality rate can be achieved through a reduction in operative interference,” the doctors wrote.
Another doctor skeptical of the new wave of obstetrics was Dorothy Reed Mendenhall. One of the first professionally trained woman physicians, Mendenhall became dedicated to issues of maternal and infant mortality after a career in pathology. In 1926, she traveled to Denmark to research the country’s birthing practices to understand why it had such lower infant and maternal mortality rates than the U.S.
Through her research, Mendenhall discovered that midwife-led births contributed to the country’s safer outcomes. She argued that due to a culture of fear surrounding childbirth, American women believed they would be safer with the elaborate tools and techniques of the 20th century physician, but it was exactly that technology that put her at a greater risk. “Hurry has become part of our national temperament and has even affected the medical profession. When hurry in the confinement attendant meets fear in the mother, the combination certainly militates against safe and sane obstetrics,” Mendenhall wrote.
But even as physicians like Mendenhall sounded the alarm, legal and cultural circumstances were working to make the midwife obsolete. In the early-20th century, 30 states enacted licensing laws to regulate midwifery. For several states, this meant subverting the midwife’s role to the physician and outlining ambiguous and sometimes inaccessible requirements. In four states, midwives had to be able to read and write, a direct attack upon the many foreign-born and Black women who worked as midwives without literacy education. Some state laws stipulated that midwives have “good moral character.”
As women’s studies scholar Polly Radosh wrote, “At worst, the midwife equaled the care given by the medical profession, and at best she offered superior care. Yet midwifery quickly became a vestige of the past or a practice associated with the southern poor. Modern American women employed obstetricians, not midwives.”
Formidable challenges to midwifery went beyond legislation and became a cultural campaign. Articles in women’s magazines like McClure’s and Good Housekeeping encouraged women to seek obstetricians for birth. DeLee was put on the cover of Time, and his pioneering use of video in medicine promoted his methods to generations of doctors. As the century progressed, a midwife-attended birth seemed backwards and unfit for middle-class, urban women.
As male physicians were increasingly sought to oversee pregnancies, the class and race-related disparities of maternal and infant mortality rates widened. The more birth became ingrained into the American medical system, the more expensive and inaccessible it became to rural and low-income women, not to mention the Black women who were barred from segregated hospitals. Ironically, obstetricians during this period like Charles Ziegler still argued that physician management of childbirth would improve healthcare for all women. He wrote, “We are passing through a political, social and economic revolution which is certain to result in giving to the worthy poor justice in necessities of life, among which must be included competent medical service, administered by those who are trained in medicine,” adding that it was impossible to train women to practice obstetrics satisfactorily.
“What could have served as a bridge between formalized medical care and midwifery—embracing both time-honored methods and knowledge from scientific research—has instead become a divisive issue.”
The 1921 Sheppard-Towner Act also exasperated these disparities. The law funded state-led maternal health programs, both in and outside of hospital settings through prenatal clinics, educational pamphlets, and health conferences. However, the distribution was uneven with many rural regions receiving less funding than programs than major cities. Through the act, some states also opted to regulate midwifery through licensure training. Those classes were difficult to attend for rural-working women, and in many cases actively discriminated against Black midwives who had comprised the majority of practicing midwives in the rural south. The act inhibited which women had access to quality healthcare, as well as limited which women could become midwives, weakening reproductive care for lower-income, rural women by two-fold.
Today, the U.S. ranks among the most dangerous countries to give birth in the Global North. Critics of childbirth in the U.S. point to the overprescribing of high-risk treatments for low-risk pregnancies. In 2018, 31.9 percent of mothers gave birth via cesarean section while The World Health Organization suggests 10-15 percent is the ideal rate for the surgical procedure. However, hospitals profit more from higher rates of intervention. Beyond the prevalence of c-sections, the high-cost of healthcare and systematic racism has further contributed to racial and class disparities in contemporary infant and maternal mortality rates.
Midwives, as of 2018, attended 9.4 percent of births, both in hospitals and at home. This percentage represents a slight increase over the past 20 years but means that the most popular way to give birth is alongside a physician. Obstetrics/gynecology is one of the few medical fields where women make up the majority of physicians (85 percent), but the legacy of doctors like DeLee has left a medical industry often resistant to the traditional and women-led science midwives perform.
Medicine’s 20th century monopolization of childbirth, though masqueraded as scientific advancement, heavily involved dismissal of traditional knowledge and female-led experience in the birth process. What could have served as a bridge between formalized medical care and midwifery—embracing both time-honored methods and knowledge from scientific research—has instead become a divisive issue. Prioritization of women’s health is pushed to the wayside when obstetricians in hospital units and midwives at homes and birth centers are viewed as opposing forces, indeed opposing careers, rather than groups that could work together to improve women’s wellness and access to healthcare globally.
Further Reading
Barbara Ehrenreich and Deirdre English, Witches, Midwives, and Nurses: a History of Women Healers (New York, NY: Feminist Press, 1973).
Alicia Bonaparte, “The Persecution and Prosecution of Granny Midwives in South Carolina, 1900-1940,” PhD Dissertation (Vanderbilt University, 2007).
P.F. Radosh, “Midwives in the United States: Past and Present,” Popul Res Policy Review 5, no. 2 (1986): 129–146.
Image credit: Engraving of forceps from William Giffard’s Cases in Midwifery, 1734 (Wellcome Collection | CC BY 4.0)
