In view of all the difficulties by which the problem is surrounded, the
uncertain results which have attended some of the most intelligent and
sincere efforts in that direction, he would be foolish indeed who
ventured to dogmatize upon the reduction of the infantile death-rate, or
the best methods to be adopted toward that end. There are, however,
certain well-established facts, certain verities, upon which I would
insist. It is perfectly obvious, for instance, that every child should
be ushered into the world with loving tenderness, and with all the skill
and care possible. The slightest blunder of an incompetent, unskilled
midwife may involve fatal consequences to mother or child, or such
injuries as are irreparable.[153] So that the very first principle upon
which everybody agrees, theoretically at least, involves the need of
important legislative reform providing for the supervision of midwives,
and the establishment of a system of training and education without
which no midwife should be allowed to practise. That such a law would
have the effect of materially lowering the rate of infant mortality, as
well as that of mothers, no one who has ever given the matter serious
consideration can doubt. From personal observation, and the testimony of
gynecologists and obstetricians of large experience, I am satisfied that
this reform alone would save many hundreds of lives each year, alike of
mothers and infants. It is appalling to think of the large number of
ignorant women who are practising as midwives. Many of them have no
conception of the importance of their work; they are often dirty and
careless, as well as ignorant of the first principles of obstetrical
science. Knowing nothing of the need or value of antiseptic precautions,
they are responsible for thousands of cases of blood-poisoning every
year, and because they are ignorant of the methods of restoring
asphyxiated infants they kill thousands of babes in the passage from the
wombs of their suffering mothers.[154]
In most states there is very little supervision of midwives; in some
cases practically none at all. New York, always rather prone to take
pride in its record upon such matters, has regulations which are wofully
inadequate. All that is necessary to enable a woman to practise as a
midwife is: (1) a certificate or diploma from some school of midwifery,
native or foreign, or (2) signed statements as to her fitness and
character from two physicians. No inquiry whatever is made into the
_bona fides_ or character of the school granting the certificate, nor
are the physicians held responsible in any way for the women they
recommend.[155] So long as the applicant meets either of the foregoing
slight requirements, the authorities must issue her a permit to practise
as a midwife. She becomes a “registered midwife,” and the title creates
an altogether unwarranted confidence in the minds of the people. It is
not only the poor, illiterate immigrants who are thus deceived, but many
very intelligent citizens are under the impression that a “registered
midwife” has had some sort of training. Immigrants coming from countries
like Germany, where all midwives have to undergo a thorough training,
are naturally unsuspicious of the fact that here we have nothing of the
kind. It is impossible to present the evil results of the employment of
untrained and incompetent midwives statistically, or even to estimate
them. Some idea may be gathered from the fact that, while the physicians
of the New York Lying-in Hospital, in 1904, attended over four thousand
confinements, 2766 _of them in the tenement districts_ among the very
poor, with only _three deaths_,[156] one midwife, in a very similar
tenement district, showed me a list of _sixty-two cases_ she had
attended with _five deaths_. And she spoke proudly of her “good record”!
[Illustration:
A FREE INFANTS’ MILK DEPOT (MUNICIPAL), BRUSSELS
]
In Germany for some years midwives have had to pass a regular
examination. In England, under the Midwife Act of 1902, they are placed
under a much stricter supervision than ever before, and are made
responsible for the cleanliness and care of mother and child during the
lying-in period of ten days. While it is felt that this law is
inadequate, it is believed that its enforcement tends to improve
conditions materially. For years the New York County Medical Association
and other medical societies of standing, supported by Boards of Health
and the leaders of the medical profession, have tried to get legislation
enacted providing for the establishment of a standard of education and
training for midwives. In every state legislation of a uniform character
should be enacted providing that no person shall practise as a midwife
or accoucheur without having first undergone a thorough training and
passed an examination set by the State Board of Regents or some similar
authority. They should be held responsible for malpractice,
incompetence, or neglect, just as physicians are held responsible. While
it is true that such a reform would inflict a certain amount of hardship
and suffering upon many women, on the other hand, it would raise
midwifery to the dignity of a profession, and provide lucrative
avocations for many other women. In any case, it is a most tragic folly
to set the hardship involved against the enormous gain to society.
It is probable that such trained midwives would command a much higher
rate of remuneration for their services than many of the incompetent
women who now act in that capacity, and that many poor mothers would be
unable to afford to employ them. Even now there are thousands of women
who cannot afford attendance of any kind at their lying-in, and doctors
tell of children, little girls ten years old,[157] for instance, caring
for their mothers through the pain and peril of parturition and for the
newly born children. The remedy for such a condition lies, not in the
employment of incompetent midwives licensed to destroy life because they
are willing to do it “cheaply,” but in the extension of free medical
service, maternity hospitals, and properly trained midwives as part of
our district nursing services. This subject of the extension of our
public medical service is a most important one. There is a tendency in
some quarters to decry everything of this nature, and to magnify unduly
the extent to which such services are abused. That they are sometimes
abused, if by that term is understood their use by those who could
afford to pay for such services, is undoubtedly true, though it would be
easy to overestimate the extent of such abuses. On the other hand, it is
certain that in many of our cities we have scarcely begun to make
provision for the needs of the suffering poor. It is astonishing to find
a manufacturing city of more than sixty thousand inhabitants, with a
tenement-house problem as distressing as that of New York City, and with
the most appalling poverty, having no city physician upon whom the
suffering poor can call by right. I do not know if there are many other
cities in the United States so utterly indifferent to the claims of the
sick poor as Yonkers, the “city of beautiful homes and great industries”
upon the Hudson, but I do know that there are many cities in which there
is a sad and shameful failure to provide proper medical care and
attention for the needy.