On Saturday, January 21, 2017, hundreds of thousands concerned about reproductive healthcare in the Trump administration participated in the Women’s March on Washington to pronounce a “message of resistance and self-determination.” Among them were members of the Midwives Alliance of North America (MANA), the professional organization that has been representing home birth midwives since its formation in 1982. “We believe that all people have a right to the highest attainable standard of healthcare,” the organization’s blog post in support of the march explained, “and that the health of women and babies depends on reducing the inequities and challenges faced by people in marginalized communities.”[1] Few hold out hope that the new administration will do much to improve the situation.
The United States is the most expensive place in the world to give birth. An average of four million births annually results in $50 billion in cumulative costs for maternity and newborn care. The high cost, however, does not result in better birth outcomes. The United States currently ranks 56th in infant mortality rates, triple the rate of Japan or Norway. Professional midwives hope to change some of these statistics by offering what they believe to be a safe, more cost-effective, less interventionist alternative to an obstetrician. Women in low-risk categories, they believe, should have the right “to give birth with their chosen provider in attendance, and in the setting of their choice.”[2]
History (and the media) tend to portray midwives as ancient relics, incompetent rabble-rousers, or determined crusaders in constant and direct opposition to obstetricians. Midwives are trying to change these images. Organizations such as MANA and the American College of Nurse Midwives have used social media to generate PR campaigns (“I am a midwife”/ “our moment of truth”), “re-introducing midwives and midwifery care as important options that should be the norm for women’s health care services.”[3]
Historians should embrace the complexities embedded in the history of midwifery and home birth, recognizing their relevance to today’s reproductive politics. This history includes moments of collaboration, not just conflict, with obstetricians. It also includes shared experiences that served not to polarize but to promote infant and maternal health across the professions. Our depictions of midwifery and obstetrical care simply must allow for unlikely alliances.
Long before MANA drew attention to health and racial inequities in maternity care, Dr. Joseph DeLee (1869–1942) made infant mortality and birth outcomes a focus of his obstetrical crusade. The arguments he made to justify his mission appear surprisingly similar to those made by midwifery organizations such as MANA. Indeed, DeLee’s claims helped to fuel the emergence of an alternative birth movement.
Dr. Joseph DeLee
DeLee was not a fan of midwives, to say the least. What he wanted more than anything was to elevate the specialization of obstetrics within American medicine. As head of the department of obstetrics at Northwestern University, and later chair of the department of obstetrics and gynecology at the University of Chicago, he played a major role in shaping and legitimizing the field. His biographer referred to DeLee as a “Crusading Obstetrician,” who selflessly raised the status of childbirth to a “scientific procedure.”[4] DeLee blamed two groups of practitioners for the high rates of infant and maternal mortality in the early twentieth century: midwives and poorly trained general practitioners. “The usual midwife of today,” DeLee testified in court in 1916, “is a very ignorant, unconscientious and really impossible person.”[5] General practitioners who delivered babies lacked adequate training because medical schools offered few opportunities for clinical experience. Most students learned obstetrics only through lecture and practice on a manikin.[6]
On February 14, 1895, DeLee opened the Chicago Lying-in Dispensary, a clinic for pregnant women and a training ground for obstetrical men, in Chicago’s Near West Side, a grim neighborhood DeLee believed was “needing the institution most.”[7] All deliveries took place at home. For cases requiring surgery DeLee opened the Chicago Lying-in Hospital, a small, 15-bed hospital in 1899.
By the 1920s DeLee’s small hospital had gained the interest of University of Chicago. As a result DeLee accepted a position at the university and a new, modern version of DeLee’s hospital was constructed on the university’s Midway campus, a foreshadowing of things to come. This was the decade when “women in alliance with obstetrical specialists decided to move childbirth to the hospital,” as Judy Leavitt describes.[8]
But this new affiliation, along with the onset of the Great Depression, jeopardized DeLee’s homebirth-based dispensary, now called the Maxwell Street Dispensary. Much to DeLee’s dismay the hospital board of directors voted to close the dispensary in 1931. DeLee, calling this decision a “calamitous action,” set to work raising funds to keep the dispensary open.[9] While fundraising he articulated a rationale for home birth that would far outlast his physical presence. “We can care for five times as many women for the same expenditure of money” as would be spent for a hospital delivery, “and we actually reduce the number of mothers dying in childbirth and thus the amount of indigency in the community,” DeLee wrote in a fundraising letter.[10] Home births were, simply put, cheaper and safer than hospital births. Why, during such a major financial crisis, would it make sense to eliminate the more cost-effective option?
Many advocates came forward in support of saving the Maxwell Street Dispensary. “It has stood out all of these years as a beacon [of]light for so many of our poor mothers, that we do not know how to plan without it,” declared one nurse. “A trip to the moon is just about as easily accomplished as a trip to the new hospital on the Midway by most of them.”[11]
Cost and distance were only the beginning of the problem for many expectant mothers. Racial discrimination also factored into the equation. African American women were routinely sent to Cook County Hospital, because it was one of the few that would admit patients regardless of race or ability to pay. Even prior to the Depression most locals viewed Cook as “the place of last resort.”[12] And Cook’s reputation wouldn’t change for decades to come. “My first child was born at Cook County Hospital,” stated an African American mother in 1972. ”They don’t treat you nice like they do at home.”[13] This was one more reason, many believed, to opt for a home delivery.
But for DeLee in 1931, unlike MANA in 2017, a woman’s right to choose where to give birth was not the main rationale for providing home obstetrics. Doctors’ training was. Yes, it was cost effective to deliver babies at home, and it provided a service to the poor who had limited access to hospital care. But it also offered the opportunity to advance the status of obstetrics by providing hands-on training in an important setting. “We can teach students and doctors how to do good routine obstetrics in the poorest hovel,” DeLee wrote. Despite his desire for childbirth to move to the hospital, he believed that the best learning opportunities took place in the “adverse conditions of the home” rather than in a “finely equipped hospital.” Students needed to learn how to treat complicated cases “under the most unfavorable conditions,” where access to hospital technology might not be available.[14]
Through successful fundraising and eventual affiliation with Northwestern University, the dispensary’s practice of home obstetrics continued, now under the name of the Chicago Maternity Center (CMC), with a new board of directors and a new medical staff under the direction of Dr. Beatrice Tucker (1897–1984).
Dr. Beatrice Tucker
Tucker had just finished her final year of residency in obstetrics at the University of Chicago when DeLee approached her about becoming the director of the new CMC in 1932. At six feet tall she struck an imposing figure and was quick to challenge DeLee or anyone else who treated her differently than her male colleagues. “He did try to get a male first, and he couldn’t get anybody down there because they were interested in making money,” Tucker remembered. “I said that I wanted to make money, too.” But she decided she liked home obstetrics, which she had already done as part of her residency under the direction of DeLee. “Dr. DeLee
believed in home delivery. He really did.” He stressed how much more students could learn from a home delivery, where the students sat with the patient during the entire labor, rather than in the hospital, where they worked in shifts. “You learn all the physiology of childbirth and you have to know that and know it well before you can really apply your obstetrical knowledge and manage and deliver a baby properly.”[15] So she agreed to run the CMC, and for forty-one years she trained medical students and residents in the basics of home delivery in the Near West Side, as the neighborhood deteriorated and then disappeared, a victim of urban renewal.
Tucker was DeLee’s ideal missionary. In annual reports she stressed how the CMC benefited both poor families and the field of obstetrics. “Caring for poor women in their homes has outstanding social values,” Tucker wrote in 1933. It helped to keep the family together and improved birth outcomes. While the infant mortality rate nationwide in the early 1930s was 6.8%, the rate for CMC births was 1.76%. The CMC was also “a school of practical social science for the doctors, students and nurses who live there.”[16] It was like a medical version of Jane Addams’ Hull House, also in the neighborhood. Tucker believed that the exposure to the “lives ‘of the other half’” provided an unforgettable experience for students, who would no longer view the laboring mother as a “case,” but rather as a “human being suffering both pain and poverty.”[17]
Most importantly the CMC provided medical students with an ample supply of “obstetric teaching material” at a time when more and more women were opting for a hospital birth. DeLee believed that both home and hospital births were key to the growth of modern obstetrics, but they were invariably at odds with each other. “Obstetric practice is in a state of transition,” DeLee declared in 1936. “It is necessary therefore to teach doctors and nurses now to care for maternity cases at home until there are enough good hospitals to deliver all the women. This cannot be expected for 20 years or more,” he announced.[18] His prediction was surprisingly accurate: when he made this claim, 37% of all U.S. births took place in hospitals; twenty-four years later, 97% did.
The problem was that the increasing proportion of women choosing hospital births resulted in a dwindling number of “sufficient clinical material.” DeLee noted in 1941 that until recently, “we had enough patients for the teaching of all our hundreds of students, but the trek of the women in Chicago to hospitals for confinement is reducing the number who stay at home.”[19] At face value it appears illogical for the man held by many as responsible for the medicalization of childbirth to raise concern about an increase in hospital deliveries. Wasn’t this exactly what he was aiming for? DeLee’s own biographer was not able to offer an explanation for it, acknowledging that DeLee’s claims of the benefits of home births were “obviously an argument against maternity hospitals, but who expects a crusader to be completely logical?”[20]
The key to understanding DeLee’s seeming hypocrisy is to view his position on home birth as more of a temporary training opportunity than an optimal method of delivery, and also as a practice that was race- and class-based. By trying to limit hospital births to those he perceived as effective training hospitals, he cornered the market on both home and hospital births, replacing midwives at home and poorly trained general practitioners in the hospital. And by utilizing a home birth clientele that was primarily poor, immigrant, or African American, he hinted at a double standard in obstetrical methods, one that would carry on well after his death in 1942. Patients who could not afford or were excluded from hospital births might be willing, even grateful obstetrical guinea pigs—particularly if their options for hospital births were limited to Cook County Hospital. And far more of these women were nonwhite than white. In 1950, for example, 92.8% of white women and 57.9% of nonwhite women gave birth in a hospital.[21]
After DeLee passed away in 1942, Tucker continued to promote the CMC as an ideal teaching institution. “Every home case we exploit for teaching to the ‘nth degree,’” she stated in 1966. “We feel medical students can learn more about medicine in the home than they can in the hospital.”[22] Part of the reason for this was the time commitment involved; the CMC crew stayed in the home from the onset of labor until about two hours after the birth. Tucker used the opportunity to teach students everything about obstetrics, from creating a sterile field to the occasional use of forceps and episiotomies.
By the late 1940s business was booming at the CMC, accounting for one of every twenty births in the city. Hundreds of medical students from the University of Wisconsin, Northwestern University, and Chicago Medical School annually completed a three-week rotation with the CMC, while interns and residents stayed for six months to two years.[23] “They enter these doors as students and become obstetricians,” announced Tucker in the 1952 annual report, with a corresponding photograph of the center’s entrance. “Medical men and women famed in obstetrics have passed through these doors. And undoubtedly, some of those going out today will leave their mark on the future.” They continued to participate in thousands of home births every year, even as the nationwide rate of hospitals births topped 97% in 1960.
During the 1960s, the number of CMC-assisted births dropped precipitously. After peaking at close to 4,000 births in 1949, the number hovered around 3,000 per year between 1957 and 1962.[24] By the early 1970s, numbers were down to approximately 1,000 per year. Two major factors help to explain the decline. The passage of Medicaid in 1965 enabled more poor women deliver in a hospital, which for most Americans, had become the standard (and desired) place to give birth. But racism, poverty, and urban decline dramatically altered the CMC’s Near West Side neighborhood. In 1930 the population was 78% white, while in 1960 it was 0.5% white.[25] Massive black migration during the postwar period, and the resulting “white flight” from urban areas, heightened segregation and exacerbated race relations.[26] Deteriorating conditions, poverty, and crime took a major toll on the community and on the CMC.
As a result, Tucker started having difficulty recruiting and keeping medical students who were primarily white and middle class and who appeared increasingly uncomfortable working in the neighborhood. “Please, in no way, embarrass students who have left the Center between February 21 to March 6,” she wrote to the associate dean of Northwestern University Medical School in 1971. “Dr. Miller was frightened by a brick thrown by a policeman, and left because he was afraid to stay. Dr. Buckley found the Center intolerable, and left.”[27] In a later interview Tucker explained that the decline of the CMC was due in part to the fact that “medical students were afraid to go out in the homes.”[28]
The real death knell for the CMC, however, was not rioting but renewal. The construction of the Dan Ryan Expressway in 1957 split Maxwell Street in two, effectively tearing the community apart. As in many other urban freeway projects that cropped up as a result of the 1956 Interstate Highway Act, the new highway benefited primarily white suburban commuters at the expense of primarily black urban residents. “For too long the history of urban renewal and highway clearance has been marked by the repeated removal of black citizens,” noted members of Baltimore’s Relocation Action Movement in 1968.[29] The Dan Ryan Expressway was clearly one of those projects.[30] Then, in the mid-1960s, Tucker learned that the CMC building was slated for demolition, one of many historic victims of an urban renewal project. Mayor Daley had chosen the historic Near West Side neighborhood as the location for a new campus for the University of Illinois.[31] Hull House was also in the path of destruction, but unlike the Maternity Center, it was saved by virtue of its status as a National Historic Landmark.
Though the building was been torn down in 1973, the legacy of the Chicago Maternity Center remains. Many of its students and interns who witnessed their first home births while on call for the center later became advocates and practitioners of home births. Others worked with childbirth educators, La Leche League leaders, and midwives to ensure that home birth remained safe and accessible to city residents. They began with DeLee’s premise that home birth could be safe, effective, and scientific and turned it into a meaningful, revolutionary experience for families rather than merely a teaching tool for practitioners.
DeLee might not have believed in midwives, but his approach to advancing obstetrics ultimately created new possibilities for them. Sometimes, legacies are far richer and more unexpected than we might have ever imagined.
Wendy Kline is Dema G. Seelye Chair in the History of Medicine at Purdue University and the author, most recently, of Bodies of Knowledge: Sexuality, Reproduction, and Women’s Health in the Second Wave (2010). She is currently writing a book on the history of childbirth in late twentieth-century America. She is also an OAH Distinguished Lecturer.
Notes:
[1] https://mana.org/blog/mana-supports-the-womens-march-on-washington
[2] https://mana.org/blog/mana-supports-the-womens-march-on-washington
[3] https://www.youtube.com/user/iamamidwife
http://www.ourmomentoftruth.com/
[4] Morris Fishbein, Joseph Bolivar DeLee: Crusading Obstetrician (Dutton, 1949) p. 11
[5] Fishbein p. 110
[6] Charlotte Borst, Catching Babies: The Professionalization of Childbirth (Harvard University Press, 1995), p. 97.
[7] Fishbein p. 51
[8] Judith Walzer Leavitt, Brought to Bed: Childbearing in America, 1750-1950 (Oxford University Press 1988), 194.
[9] Fishbein 211
[10] Fishbein 212.
[11] Quoted in Fishbein, 216-217.
[12] Beatrix Hoffman, Health Care for Some: Rights and Rationing in the United States since 1930 (University of Chicago Press 2012), p. 9.
[13] Quoted in The Chicago Maternity Center Story https://www.kartemquin.com/films/the-chicago-maternity-center-story
[14] Quoted in Fishbein, 212-13.
[15] “Recollections: An Interview with Dr. Beatrice Tucker,” by Diane Redleaf and Pat Kelleher, in Health and Medicine, Journal of the Health and Medicine Policy Research Group,” vol 1 issue 4 1983.
[16] First annual report of the Chicago Maternity Center, 1933, p. 27.
[17] First annual report p. 27
[18] Joseph DeLee, 1936 CMC report, p. 3.
[19] Joseph DeLee, 1941 CMC report, p. 8.
[20] Fishbein 212.
[21] Borst, 157
[22] CMC 1965/66 annual report; reprint of Lois Baur’s article/ interview in Chicago’s American, “The Woman the Babies Meet First.”
[23] 1951 annual report [NP numbers]
[24] In 1964 the total number was 2132; 1965 it was 1844, and in 1966, the number was down to 1700
[25] http://www.encyclopedia.chicagohistory.org/pages/878.html
[26] Arnold Hirsch, Making the Second Ghetto: Race and Housing in Chicago 1940-1960 (University of Chicago Press, 1998), p. 24.
[27] Tucker to Dr. Richard Kessler, 3 Mar 1971, Beatrice Tucker Correspondence c. 1940-1972, Chicago Maternity Center Papers, Northwestern Memorial Hospital Archives, Chicago.
[28] “Recollections: An Interview with Dr. Beatrice Tucker” Tucker Correspondence.
[29] RAM position paper, January 1968, quoted in Robert Geoelli, Environmental Activism and the Urban Crisis: Baltimore, St. Louis, Chicago, Temple University Press, 2014, p. 83
[30] See Natalie Y. Moore, The South Side: A Portrait of Chicago and American Segregation (St. Martin’s Press, 2016, p. 87).
[31] http://www.uic.edu/depts/uichistory/
