The Rise of Obstetrics
Before 1750, childbirth was in the hands of women. Midwives attending to births were mostly passive in their intervention in labor and generally let nature takes its course.a Childbirth had a social aspect to it, and local women expressed their love and care for one another and supported each other in a mutual life experience. b Women would “lie in” for 3-4 weeks, as other women took over house responsibilities. b The mother rested, regained her strength, and nursed without interruption. b It was an occasion for female solidarity, which included a woman’s entire social circle, family, and friends. b
At the end of the lying-in period, the mother threw a groaning party for all the female helpers. b This was a way to express appreciation and compensation for their help. b The years before 1750 are commonly called “the Age of the Midwife” b and a time of “social childbirth.” Birth was usually routinely successful, and colonial midwives were very successful attendants. b
However, after 1750, men began to train as physicians abroad, including the “new midwifery” in Europe, and returned to practice in America’s colonial towns and cities.a At the time, America had no medical schools, hospitals, or organized medical profession, such as European countries. b Upon coming back, men brought with them skills and knowledge that American midwives could not offer. b
Initially, American doctors saw attending childbirth as a position to be shared between themselves and trained midwives. b They believed that natural processes were adequate and that midwives could attend normal deliveries, while they would be called in for more difficult ones. b
Towards the end of the late 18th and early 19th century, formal medical education took rise, with 800 medical schools being founded. However, most of these schools were proprietary, which meant they were primarily profit-making schools owned by doctors who also taught there. Those who attended graduated with no practical medical or clinical knowledge. If a doctor received training, it widely varied. Several varieties of “doctors” practiced at the time, including empirics, sectarians, botanists, homeopaths, eclectics, and minor sects like hydrotherapists. b Some doctors were called “elite” meaning they traveled abroad for training. b Overall, being a doctor had low professional standing in the eyes of most people, unlike the way doctors are viewed today.
Reputable medical schools began to form with the Medical College of Philadelphia in 1765 and Harvard Medical School in 1782. Obstetrics was the first medical specialty at early elite schools, considered to be the foundation of medical practice. b Dr. Walter Channing was a Professor of Midwifery and Medical Jurisprudence at Harvard and later the first Dean of Harvard Medical School.
However, women had a particularly difficult time entering into what came to be known as obstetrics. In 1850, Harriot K Hunt applied again to Harvard Medical School, was admitted, but medical students published objections, saying “We object to having the company of any female forced upon us, who is disposed to unsex herself and to sacrifice her modesty by appearing with men in the medical lecture room where no woman of any true delicacy should be found.” Hunt was forced to withdraw. As a result of discrimination, women had to found their own institutions so they could get clinical training. b One such hospital was the New England Hospital for Women and Children in Boston, in the 1860s. b
In 1848, due to the widespread diversity of doctors, the American Medical Association was founded to exclude “irregulars” from practice and to set enforceable standards for medical practice. By 1901, an editorial appeared in the Journal of the American Medical Association discussing the problem of “overcrowding” in the doctor profession.
Meanwhile, in the 1890s, major reforms linked medical education to hospitals, with Johns Hopkins being the first model to emphasize both science and clinical experience. Johns Hopkins was also the first coeducational elite school. b
Two major documents were critical in the widespread reform of Medical Education. In 1910, the (Abraham) Flexner Report was published.a This report led to tougher state laws and setting standards for medical education. b The report established that 90% of doctors were without a college education and most had attended substandard medical schools, such as proprietary schools. b
In 1911, J Whitridge Williams, Professor of Obstetrics at Johns Hopkins, surveyed the teaching of obstetrics in medical schools and found it to be deplorably inadequate. b Some professors confessed their students were no more skilled than untrained midwives. b At the time, 120 medical schools gave a four-year course but only half were accredited by the AMA. Most medical schools in 1911 only required a high school diploma, b and most were proprietary. b
Williams argued that even in the best schools, there was little clinical experience in obstetrics. b He argued that there should be fewer medical schools and all should have higher standards for admission as well as qualified instructors. b Williams said obstetrics should be taught as a fundamental part of scientific medicine, b and he urged that midwives should be abolished. b He also urged the founding of maternity hospitals for advanced training for doctors. b
The aftermath of all these reforms is that medical education became inextricably linked to hospitals as training for students, and in 1930, the American Board of Obstetrics and Gynecology (ACOG) was established. One of the primary purposes of the Board was to provide hospitals with criteria by which to judge the capabilities of staff and general practitioners. b
a. Thomasson MA, Treber J. From Home to Hospital: The Evolution of Childbirth in the United States, 1927-1940 [Internet]. National Bureau of Economic Research; 2004 Nov [cited 2016 Mar 15]. Report No.: 10873. Available from: http://www.nber.org/papers/w10873
b. Wertz RW, Wertz DC. Lying-In: A History of Childbirth in America, Expanded Edition. New Haven: Yale University Press; 1989. 302 p.
c. 09 JMGSN, 2014. Tragedies to transplants, the history of Longwood – The Boston Globe [Internet]. BostonGlobe.com. [cited 2016 Mar 15]. Available from: https://www.bostonglobe.com/lifestyle/health-wellness/2014/11/09/tragedies-transplants-history-longwood/5I7WEMXXIcxUx2BbvaoVAN/story.html
d. Brigham and Women’s Hospital: Integrated Residency Program in Obstetrics and Gynecology [Internet]. [cited 2016 Mar 15]. Available from: http://www.partnersobgynres.org/aff-bwh.asp
e. Long T. Jan. 14, 1794: First Successful Cesarean in U.S. [Internet]. WIRED. 2011 [cited 2016 Mar 16]. Available from: http://www.wired.com/2011/01/0114caesarean-first-us/