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XI

ADEQUATE MATERNITY CARE

WHILE it is true that the newest immigrants turn to the midwife automatically, there is some evidence that with longer residence in this country the foreign born naturally forsake the midwife.

In the article previously quoted, Dr. Charles V. Chapin said:

There is evidence to show that midwifery is decreasing. Doctor Woodward stated that in the District of Columbia between 1896, the date of the adoption of the law regulating midwives, and 1915 the number of births attended by midwives in the District of Columbia fell from 50 per cent of the total births to less than 10 per cent. In 1918 it was 5.5 per cent. This was due chiefly to the elimination of midwives by examination. In New York, in 1905, 42.1 per cent of all births were attended by midwives, while in 1917 the per cent was 33.5. The decrease has been especially rapid since the opening of the war, which is interpreted as indicating that it is the newcomers who are most inclined to rely upon the midwife. In Providence the proportion of births attended by midwives increased with the increasing tide of Italian immigration up to 1913, when more than 33 per cent of all births were attended by them. In 1918 the percentage was 27.5. In Providence there has been an almost complete disappearance of the Jewish midwife. Ten years ago nearly 150 births annually were attended by Jewish midwives. Last year there were but 4 so attended, although we have a Jewish population of nearly 20,000. This seems to be due largely to the appreciation on the part

of Jewish women of the value of medical service. In Rochester the number of midwives and the number of births attended by them has decreased during the last eight or ten years.

If we would hasten the displacement of the present midwife's practice, we must provide substitutes that will be understood by and acceptable to the people who now use midwives most extensively. To overcome the traditional reason for selecting the midwife, and the so-called sex prejudice against a man doctor, is a matter of education. The economic reason for using the midwife cannot be directly overcome by education, although people will often pay more if they feel sure that by so doing they will get something much better. So many of our immigrant families live under severe economic pressure, where every dime must count, that a new maternity service cannot cost much more than the midwife if it is to be readily used, and at least as much convenience to the family at the time of confinement is to be assured.

When the immigrant looks about for a substitute for the midwife, he finds the private physician and certain organized medical resources-the maternity hospital, the out-patient system of maternity care, and various clinics. The Maternity Center Association of New York estimated that in the year 1917, midwives cared for about 40 per cent of the total number of births in the entire city; that about 30 per cent were cared for by the out-patient system of maternity care, plus the maternity hospitals themselves-that is, by an organized maternity care system. The remaining 30 per cent of confinements

were cared for by private physicians. The proportion of cases receiving care through an organized system of hospital and maternity out-patient departments is larger in New York City than perhaps anywhere else in the country.

In most communities the only available substitute for the midwife at the present time is the private doctor. We have seen some of the reasons why many immigrant families will employ a private doctor at the time of the mother's confinement only with reluctance, or only in an emergency.

The doctor often does not speak the language of the family. He charges more; he renders less service. Does he give better service from the point of view of the immigrant family? A Jewish woman said to an American visitor, speaking of the doctor and the midwife: "The doctor, even the professor doctor, he comes to your house to get your baby. He hurries you up; he hurries you up; he hurries you up, and that is not so good." What Dr. Whitridge Williams says in the article quoted in the last chapter about the inadequate teaching of obstetrics and the inadequate training of the average practitioner for this work, is not known by the immigrant mother, but she and her friends have felt some of its results. If the fee that they pay the doctor is so low that he can or will give them only very little time, and hurries them up, and uses forceps to take the baby, they may make a comparison with what the midwife will do for them to the advantage of the latter. Not a few immigrant families who have been interviewed give exactly this testimony, expressed in their own way and not in technical terms.

Facts of this kind are not a criticism of the medical profession as an agent of maternity care. They are a substantiation of the statements of Doctor Williams and other leading physicians as to the inadequate training in obstetrics which many physicians now in practice received during their medical school days, and the inadequate training which many medical schools even now provide.

If, through various means, the amount of obstetrical practice brought upon the rank and file of practitioners were increased, it would tend to increase the fee rates and also the haste on the physician's part which is now one of the chief evils in obstetrical practice. So large an amount of the practice of obstetrics among the foreign born is now in the hands of midwives that the medical profession has everything to gain by seeing that suitable substitutes for the midwife are provided under real medical supervision. The impossibility of the private physician acting at this time as this substitute for the masses of the foreign born should be frankly recognized.

An adequate substitute for part of the midwife's service, supervision, and nursing care before and after confinement, is provided by public maternity clinics.

THE PRENATAL CLINIC

Prenatal clinics are now established in many cities under the auspices of private organizations or departments of health, as centers to which pregnant women may come for examination and advice, whether these women employ their own physicians

care.

or go to an organized teaching system for maternity The advantages of obstetrical diagnosis and of supervision and education by the nurse in the woman's home during pregnancy and the postpartum period, can be provided irrespective of the care at confinement.

One of the great limitations upon the extension of this system has been that many private physicians have been unfamiliar with the prenatal clinic or with its benefits. Others have been unwilling to make use of it because they regarded it as an interference with their practice. For these and other reasons prenatal clinics have made little headway in persuading the private practitioner to send his patients to them for examination and for nursing service.

In several cities in which a system of supervising the midwife has been well worked out, the prenatal clinics play an important part in this connection. The nurses are in contact with the midwives, the midwives bring their cases to the clinic for consultation, and so the system of clinics with nursing service not only assists the mother, but makes the supervision of the midwives more efficient. It tends to help the better midwives and to drive out the poorer.

Since midwives are so predominant a factor in maternity care among the foreign born, it is of the first importance that prenatal clinics, maternity hospitals, and other facilities for good maternity care shall make a special effort to work with them. Some maternity hospitals have developed social-service departments, which make a special effort to do this, but they seem to have made only a limited contribu

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