At the end of the 2022 school year, I had the chance to write a research paper on any topic of my choosing. I chose to write about the switch from traditional midwifery to Obstetrics around the turn of the century. In the paper, I also explored the implications that this medicalization had for communities of color.
In case you're looking to read 17 pages about birth equality, the paper is below.
The Switch Between Midwifery and Obstetrics: The Rise of Medicalized Birth and Its Impact on America
May 10, 2022
In 2017, professional tennis player Serena Williams almost died during childbirth. She underwent an emergency Cesarean Section (C-Section) and woke up paralyzed, short of breath, coughing, and in excruciating pain. Having been in hospital settings as a serious athlete, she knew enough about her own body to understand that something was seriously wrong. However, she was continually ignored and gaslit by medical staff, being told that the medication she was on was “making her talk crazy.” After hours of begging for tests to be run she was finally taken seriously, and they found a life threatening pulmonary embolism that ended in multiple more emergency surgeries. In an essay she published for Elle magazine, she wrote that eventually “being heard and appropriately treated was the difference between life or death for me.” Even though Williams is a celebrity, her story and medical invalidation is a surprisingly common reality that Black women face in America. The answer as to what caused this medicalized and deeply inequitable system lies in how birth has evolved over the years and who has cared for birthing women. The historical switch from traditional midwifery to obstetrics, initiated by the Flexner Report, had fundamental disproportionate effects on lower class communities and communities of color, over time resulting in the deeply flawed and unequal way that American society treats birth.
A midwife is a professional who cares for women during their pregnancies, attends their births, and provides them postpartum support. Midwifery is as old as childbirth; for as long as people have been birthing, community midwives have rallied around them in support. It can be traced back to the paleolithic era, or 40,000 BC. Midwives support physiological and community birth, which is natural and intuitive birth. They are known for recognizing the difference between intervening and letting a natural process unfold, and as such, have around a 90% rate of vaginal birth success. They don’t see birth as something that requires routine medical intervention, and often intervene on a less regular basis. Midwives don’t attend medical school, so do not perform surgery, and often will not work with people who are considered to be high risk.
Obstetrician/Gynecologists, hereafter referred to as OBs, are medical doctors who specialize in childbirth. They perform surgery, take complicated cases, and, in America, are almost always the first person that someone will go to upon finding out they’re pregnant. OBs will care for over 77% of pregnancies from the first trimester through birth, meaning that they’re the default provider option for a majority of American women. It is important to acknowledge the beneficial effects that OBs have had on birth: for high risk pregnancies and babies, they are crucial leaders of the birth team, bringing in vital knowledge and specialized surgical skills. However, because only 6 to 8 percent of pregnancies in the US are considered “high risk,” the prevalence of extensive care that OBs provide does not correlate with the amount of people who need it.
OBs and midwives are different: OBs are trained to view birth as a medical event, one that takes place in a hospital and is almost always closely monitored. They’re knowledgeable about every possible scenario, but as such, are sometimes unable to sit back and allow a normal birth to unfold on its own. For example, a 2019 study found that patients birthing with OBs were 30-40% more likely to receive a C-Section. Their more lengthy medical training means that they use more interventions with their patients, which can lead to more complications farther down the road. Midwives help people birth babies both in hospitals and at home, and are generally trained to view birth as a normal process, as opposed to a medical event. One of the biggest differences between midwives and OBs is their views on pain: because of OB medical training, they tend to recognize pain as something that needs to be taken away from the patient, and because of that, are 30% more likely to give an epidural. Midwives view pain as productive, and are more likely to help a patient work through it in other, more physiological, ways. Midwives and OBs can work together in hospitals, but midwives make up a very small percentage of birth professionals, attending about 8% of American births a year. However, to really understand the history of childbirth and how the United States came to have two different models of caring for birth, it’s important to start with history.
Midwifery is one of the only practices that has been relatively synonymous worldwide, and, historically, the bringing of new life into the world was seen as an important rallying point of connection within the community. Often, midwives would be trained once they had borne children themselves, and would pass down knowledge via apprenticeships and experience. Many had knowledge of herbs and other natural remedies that helped reduce risks associated with birth. Partially because of this, and partially because of the mystique surrounding birth, midwives were sometimes persecuted as witches, especially in early practice. For much of history, midwives were not regulated, instead being chosen and trained by the women who had come before them. However, some of the earliest laws guiding the practice of midwifery appeared in 15th-century France and were instituted in part to reduce what was believed to be the practice of witchcraft among midwives. The first official licensing of midwifery came in the 17th century, when midwives were regulated by the Church of England. However, while official midwifery licensing started in England, the precedent for regulation began to extend to America as well.
In America, the practice of midwifery started much like it did in the rest of the world. Midwives cared for and were respected by their communities, as well as being prevalent directors in the birth room. In fact, “Midwives attended almost all births in the American colonies, practicing from their homes and passing the skills they had brought from Britain from one woman to another informally.” Many early midwives were also Black, caring for their communities both when they were enslaved and before they were included in standard medical care. White Colonial midwives and Black midwives didn’t often practice in the same ways or places, and while later legislation affected them all, early legislation was targeted towards White midwives, as Black midwives during this time were still slaves. In 1716, the licensure of midwives in America started with New York requiring documentation with the state in order to practice. This is interesting in historical context, because the first permanent general hospital was not built until 1752, meaning that they began to regulate midwifery 36 years before they set up a place to care for people if they had real medical problems. In 1765, the first official school for midwives was established by Dr. William Shippen, who was teaching out of a department in the College of Philadelphia. However, not many attended it because it was expensive, and believed that knowledge about birth was better gained through experience and not through the teaching of a male. After the Civil War there once again was movement on the childbirth front, and in 1888, the American Association of Obstetricians and Gynecologists formed. This unified the field of OB and further created a steady front to prove a barrier to the practice of midwifery.
While there had been previous movement towards regulation and reduction of midwifery, tThe Flexner Report was the turning point that contributed the most to the drastic decline of midwifery and rise of obstetrics. This report was the catalyst for change and reason that OB practice is the default model of care in the United States. It was published in 1910 by Abraham Flexner, a researcher at Johns Hopkins who was a part of a research group known as the Hopkins Circle. The Hopkins Circle, commissioned by the Carnegie foundation, joined to work on a project aiming to reform American medical education, and the Flexner Report was both a culminating critique and proposed way to move the system forward. In 1910 the Carnegie Foundation published the Flexner Report, which among other things, asserted that obstetrics was making “the very worst showing” in medical proficiency. Flexner challenged anything that was not rooted in a strict medical background, such as physiological birth. As an extension of this, he wrote that the “increase of doctors: allopathy, homeopathy, osteopathy, have no cut figures in this discussion.” This primed the field to ignore the traditional practices that had been relied upon before, instead of seamlessly integrating them into the next generation of medical education. Flexner took it a step further, asserting that although “the homeopaths admit the soundness of the scientific position, they have taken no active part in its development.” His wording made it seem that traditional providers were standing in the way of scientific progress, and as such, began to establish a mistrustful divide between natural and medicalized models of care.
Overall, his impact on medicine was massive, changing a relatively disorganized American system into a science-based Germanic system. With the Flexner Report came the assumption that doctors would be trained as scientists first and relationship oriented physicians last, if at all. As a result of this, incredible scientific discoveries were made, such as vaccines for diphtheria, tuberculosis, and tetanus. Ultimately though, fields that required more of an emphasis on human relation, such as the birth field, suffered.
The birth field was hit hard by the Flexner Report and the offshoot legislature that it triggered. The Flexner Report was the first report of its kind, but it was not the last, with more and more publications calling for birth to happen in a medical environment. OBs like Dr. Joseph DeLee, founder of Chicago Lying-In Hospital and popularizer of the use of forceps, came to power. He advocated for birth to be viewed as a destructive pathology and thought that with new medical technology, “the midwife would be impossible even of mention.” Having completed medical school in the Flexner Report era, DeLee changed hospital birth to use routine interventions on every person in labor, a change that still prevails today, seen in regular cervical checks, electronic fetal monitoring, and birthing in a supine position. The Flexner impact lasted: over the 20th century, midwives were systematically taken out of birth settings, and by 1980, they attended only 1.1% of all births in America.
The Flexner Report also had huge implications on race and racially diverse practitioners. Flexner recommended that Black physicians, who made up 2.5% of the medical field, only serve Black communities, banning them from attending traditional medical school. However, because his report led to the closure of medical schools deemed ‘unworthy’, many schools suddenly became unavailable. In a hundredth anniversary recap of the Flexner Report, JSTOR noted that “the country’s 148 medical schools were whittled down to sixty-six. Of the seven schools for African-Americans, only two remained standing.” This led to an issue within the birth world, because many of the practicing midwives were Black, unable to attend the medical schools that would have been necessary for them to practice legally. It also was the beginning of an equity problem that is still prevalent today: there are very few physicians of color, and only 5% of all doctors identify as Black. Because the Flexner Report made it so difficult for non-white people to obtain medical training, many didn’t bother to, which set the stage for a contemporary disconnect between a privileged, White world of medicine and a more diverse population of patients.
After the immediate impact of the Flexner Report, the entire birth field suffered from the lack of midwifery with the rise of Twilight Sleep and disempowerment during the 1915-70. This was an offshoot of American medical rise to power and general trend of over-medicalization. Twilight sleep was a cocktail of morphine and scopolamine given to women in labor in an effort to reduce pain, effectively disorienting them and leaving them with no memory of the experience. A medical research company wrote that:
While scopolamine prevented memory formation, it did not prevent pain, therefore to reduce the screaming and thrashing of women during labor…In addition, Gauss restrained the pregnant woman on a padded bed using leather straps and inserted oil-soaked cotton into her ears to eliminate the woman’s hearing.
Scopolamine is said to affect the memory in a pattern similar to Alzemheir’s Disease. Women woke up after receiving Twilight sleep medication without their babies, restrained to the bed, and with no perception of how their births unfolded. Oftentimes, they would not realize that they had given birth, and when handed their baby, did not recognize them. Because the need for movement in labor in order to have an uncomplicated delivery was not able to be achieved if the laboring person was unconscious, “twilight sleep was associated with increased use of forceps during delivery, prolonged labor, and increased risk of infant suffocation.” This medicalized approach to birth disempowered women, intentionally taking them out of an experience that should have been emotional and introspective. It also comes back to the idea that OBs are more likely to attempt to take pain away, rather viewing it as a positive part of birth. Twilight sleep was popular: 2,950,000 babies were born in 1920, and Twilight Sleep was used in about 75% of them. The rise of Twilight Sleep emphasized the medicalization of the field, which was congruent with the American medicalization trend in that time period. According to Penn Nursing, “between 1909 and 1932, the number of hospital beds increased six times as fast as the general population.” The entire country was moving towards medicalization, but they failed to realize that birth, a physiological process, was unduly harmed.
The eradication of midwifery in American society disproportionately affected people of lower economic classes, painting obstetrics as the safe option for wealthy people. Because of this, many switched to in-hospital birth because of wanting to be seen as willing to pay more if it meant making the best choice for their baby and pregnancy. This was also a huge contributor as to why medicalization in birth became so prevalent, so quickly. Historically, midwives served poor women, sometimes providing services in exchange for non-monetary compensation. However, after the publication of the Flexner report, obstetrics began to promote itself as the safer option. A male OB named William Shippen was among the first male birth attendants in Colonial America, quickly becoming popular amongst the elite of Philadelphia. An article published in JSTOR asserts that this is likely because of the perception that physicians were more trained than midwives, even though Shippen himself learned under a midwife. However, not only was birth switching to an obstetrical model of care, it was moving specifically into hospitals. In fact, “one report recommended hospitalization for all deliveries and the gradual abolition of midwifery. Rather than consult with midwives, the report argued, poor women should attend charity hospitals, which would serve as sites for training doctors.” Obviously, moving economically disadvantaged populations into hospitals to be tested upon did not result in better care or outcomes for them. However, obstetrics was painted as the “safe choice” for birth, and because of social pressure, the women who benefited from midwifery care turned into the population most harmed by OB.
Furthermore, the loss of midwifery was based in racism and hurt populations of color more dramatically than it hurt anyone else. It hurt populations with less economic privilege in general, but it especially affected Black communities. By erasing cultural competence around birth that was passed down through midwifery apprenticeships, women who would have become Black midwives never received the training, which further took Black providers out of birth. In the 1940s, Black midwives, sometimes known as granny midwives, still attended around 75% of all births in the Southern United States. However, they faced laws that specifically prohibited their practice earlier than most, beginning in the early 1800s. An article in JSTOR found that in the South, “only 8 percent of Black births were attended by a physician, as compared to 79 percent of White births.” This meant that up to this point, Black communities had been served primarily by midwives; so the rules that cracked down upon them impacted the Black communities far more than the White ones. Traditional Black midwives “bridged the gap between disenfranchised communities and the medical system,” keeping birth safe and traveling all over the South. It was these populations that relied the most on midwifery, and these populations who were left deeply vulnerable when midwives were driven out. As well as being ousted by regulation, Black midwives were the targets of a hate campaign led by leaders of the Obstetrical field. In a country meeting that took place in 1910, the Johns Hopkins professor and OB Dr. Allan Freeman said of granny midwives: “There is no doubt that tens of thousands of women are being absolutely murdered by ignorant midwives. Every one who has ever practiced obstetrics knows how filthy and dirty, how officious and meddlesome these women are.” Dr. W.P. Manton was of similar mind as Dr. Freeman, and stated that OBs should be in “legislative control of these carriers of disease and death.” The prevalent anti-midwife rhetoric led to legislation being passed, such as the Alabama State Board of Health’s assertion that every midwife must pass a training based on their “Manual of Midwifery.” The Manual of Midwifery was one of many offshoot legislations that was triggered by the publication of the Flexner Report. It included the rule that every baby must be placed in a separate place to sleep than their mother, even if their only option was a cardboard box, which was clearly a ridiculous standard for midwives to follow and contributed more to their disdain. By 1931, only 3,568 traditional Black midwives were left practicing, a number that is almost identical to the amount of Black midwives who practice today, a hundred years later.
The lack of modern midwifery is the root cause of the race-based birth disparity that we see today, as medicalized birth has a history of harming non-white bodies. When midwifery was removed from traditionally Black communities, the subpar care that they received afterwards set a precedent for the standard of care that they receive today. In the United States of America, Black babies are about 2.3 times as likely to die as White babies: 10.8 out of 1,000 Black babies die, as compared to 4.6 out of 1,000 White babies. Linda Villarosa of the New York Times pointed out that this racial disparity is even wider than it was in 1850. The Department of Health and Human Services found that Preeclampsia and Eclampsia (a condition occurring in pregnancy that causes high blood pressure and seizures) are “60% more common in African American women and also more severe.” This is likely because of medicine’s history of ignoring Black women; symptoms of Preeclampsia include feeling ill or unwell, and often those complaints get brushed off by medical professionals. Other than poor care, there is no predisposition to explain why the Black maternal mortality and morbidity is so much higher than the White one. Difference in financial status between races has also been studied, as it has been a past argument about why birthing as a Black woman is more dangerous. However, the cause of poor care is not that communities of color cannot afford it. Many influential and wealthy women of color have had unprecedentedly dangerous births, such as Serena Williams mentioned above, or Tatyana Ali, a Harvard-educated actress and performer who is well known for her role in The Fresh Prince of Bel-Air. In an essay published in 2020, she wrote that her “low risk pregnancy resulted in extremely questionable actions on the part of those attending and an emergency C-Section… one doctor slammed his forearm on top of my belly in order to force my son down as though I were a tube of toothpaste.” This type of mistreatment is not uncommon for Black women to experience during birth, and proves that regardless of your status or money, it is still inherently dangerous to give birth as a Black woman in America. Even setting aside outcomes, Black women are more likely to experience complicated births, with a study showing that “cesarean sections were 40 percent more likely among Black women as compared with White women.” This could be a result of the obstetrical field not putting as much effort into keeping Black women out of major surgery, or could be an after effect of non extensive prenatal care.
Currently, there are very few Black midwives who practice, and even fewer who practice in an out of hospital setting. However, when Black patients are cared for by Black providers, outcomes improve. A study from Stanford found that when Black patients in Oakland were cared for by Black doctors, rates of screening for basic health conditions went up by 47 and 72 percent. However, because Black midwifery has not yet recovered from the historical ousting, there has not been a study that looks at how Black patients’ outcomes are affected when cared for by Black midwives. Recently, the medical field has begun to recognize that the field of Black midwifery is something that needs to be studied, and 7.1 million dollars was newly allotted to an Illinois study that will look at how Black midwives affect Black maternal and infant mortality.
As infant mortality is also an important factor in how Black patients experience care, it is important to note that more complicated births also have an affect on the success of the babies that are born. An APGAR score is a ranking of Appearance, Pulse, Grimace, Activity, and Respiration, and is assessed on a scale out of ten (two points given in each category) for every baby who is born, regardless of setting. APGARs are usually taken at 1 and 5 minute intervals after birth. A study conducted in 2016 by the American College of Obstetrics and Gynecology with over 9.3 million patients found that infants born to two White parents are more than twice as likely to have an APGAR score of 10 at the 5 minute mark than infants born to two Black parents. This data shows that Black babies feel the effect of complicated birth, and could potentially be attributable to the stress put on Black women birthing within the American hospital system. A more stressed out person leads to a more stressed out pregnancy, which in turn, leads to a more complicated and challenging birth for both the mother and baby.
While Black populations and people of color have been the most impacted by the obstetrical system, it has affected everyone who passes through its doors, which is a massive contributor as to why the United States is so behind the rest of the world in maternity and perinatal care. Data from the entire country proves that the detriments of the system reach far and wide. In 2018, the Commonwealth Fund published a comprehensive report about the prevalence of midwifery in the world and what that meant for the ensuing maternal mortality rate. They found that out of the 11 most developed countries in the world, the United States had by far the highest maternal mortality, with 17.4 deaths per 100,000 live births. (Appendix A.) The next highest was France, with 8.7 per 100,000. The report found that in America,“(ob-gyns) are overrepresented in its maternity care workforce relative to midwives” but also that, compared to the world, there is a shortage of American birth professionals in general. Appendix B shows that the United States has the second lowest number of providers per 1,000 live births, and the lowest ratio of midwives to OBs at 4:11. To show the difference that is made when birth professionals are in enough supply, Sweden has 78 birth professionals per 1,000 live births, a 66:12 midwifery ratio, and a maternal mortality rate of 4.3/100,000. Their maternal mortality rate is over four times lower than the one in the United States. It’s possible that some of the disparity could be explained by a shortage of professionals; logically, it would make sense that patients receive lower quality care when OBs are overloaded and unable to invest as much time in them. Again, this problem could be solved by training a greater number of midwives and reintroducing physiological birth into the medical world. Countries around the world, and specifically European countries, have had success with their midwifery-based systems in lowering maternal mortality. The United States is the only developed country in the world to have a rising maternal mortality rate (Appendix C), and based on international research, it would not be unfair to assume that a more midwifery-based system would take steps towards stabilizing and lowering it.
From the beginning of history, through the Colonial Era and the Flexner Report, all the way up until contemporary times, midwives have held their communities up, providing compassionate and informed care. Modern American women have felt the first hand impacts of birthing in a system that does not prioritize the integration of midwifery, seen in the abysmal maternal and infant mortality rates. Further within this group, Black women and families of lower economic status have felt everything more acutely, as midwives had and continue to have the most impact on their well being. Midwives, above all, are life saving care providers, and the unforgiving shift from a midwife-led birth system to an obstetrician-led birth system has been a key driver of birth inequality.
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