The Japanese Journal of American Studies, No. 17 (2006)

Gender Ideology in the Rise of Obstetrics

Naoko ONO*INTRODUCTION
At present, obstetrics is a major specialty in the ﬁeld of medicine in
the United States. However, until the early twentieth century, there wasno agreement on what constituted an obstetrical specialist, and different
types of medical practitioners were involved in the practice of obstetrics.
In 1910, approximately half of all the births were attended by midwives,and most of the physicians who attended the births were general practitioners and not obstetrical specialists.1
Obstetrics struggled to achieve respect and recognition as a specialty
during the time when the ﬁeld of medicine in the United States wasrebuilding its professional status and striving to achieve legal protection
for its services. However, as Charlotte G. Borst states, “the professionalization process for obstetrics differed from that of other medical specialties.”2 General practitioners argued that obstetrics was a part of theiroverall practice and thus obstetrics lacked recognition and respect as a
specialty. John Whitridge Williams, Professor of Obstetrics at Johns
Hopkins University, expressed regret at the lack of appreciation by his
medical colleagues with regard to the importance of obstetrics. He statedthat “even in such an institution as the Johns Hopkins University, several
members of the medical faculty still believe that the obstetrician need
Copyright © 2006 Naoko Ono. All rights reserved. This work may be used, withthis notice included, for noncommercial purposes. No copies of this work may
be distributed, electronically or otherwise, in whole or in part, without permission
from the author.
*Associate Professor, University of Toyama

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only be a man-midwife, who is content to eat the crumbs that fall fromthe rich man’s table.”3 Similarly, Joseph Bolivar DeLee of Chicago deplored the lack of professional recognition and respect for obstetrics.
“The public has no respect for the obstetrician. He is looked down upon,
not alone by the people, but by the doctors themselves.”4 Therefore,
obstetricians in the early twentieth century strove to make obstetrics aprestigious branch of medicine, similar to surgery.
Pamela S. Summey and Marsha Hurst review the rise of obstetrics andgynecology as a specialty from 1920 to 1980.5 They argue that from theearly 1920s through the late 1930s, obstetrics and gynecology organizeditself as a profession. The primary goal of obstetrics and gynecology “hasbeen to enhance its public image and professional prestige, to become
ﬁrmly enough established in medicine so that its boundaries would besecure, to expand its sphere of expertise beﬁtting a major specialty, toestablish and enforce its own entry and exit criteria, to train only the best
qualiﬁed and be competitive with other ﬁelds in recruiting the mosttalented, and, in the process, to have a ﬁrm hold on its paying clientele.”6
However, these goals were complicated by two major contradictions,which were the basis of obstetrics and gynecology. The ﬁrst contradiction was related to its two parents, surgery and midwifery. Obstetrics andgynecology inherited techniques, knowledge, and skills from the surgeons and received the human touch from the midwives. Summey and
Hurst argue that obstetrics and gynecology has been engaged in a stateof continual conﬂict with regard to the philosophies of conservative andactive obstetrics. The matter was collectively resolved in favor of active
obstetrics because its controlling role was consistent with professional
growth and development and with the expansion of its market. The second contradiction was related to the relationship between the ﬁeld andits women clients. As Summey and Hurst argue, the ﬁeld of obstetrics
and gynecology requires women for its existence; however, it must minimize its dependence on the “second sex” in order to acquire status andpower in the medical world. “In other words, ob/gyn’s relation to women
both deﬁnes and degrades it as a medical specialty.”7
The ﬁeld of obstetrics and gynecology has focused on the physicalconditions peculiar to women and their reproductive systems. The identiﬁcation of obstetrics and gynecology as a specialty catering to women
was a degradation compounded by the fact that a considerable amountof the obstetrician’s work was formerly performed by female midwives.
This paper aims to explore the gender ideology in the specialty of ob-

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73

stetrics during the period of professional establishment and traces theprocess of resolving the contradictions mentioned above, namely, thephilosophical conﬂict between conservative midwifery and active surgery and the relationship between the ﬁeld and its women clients. The
gender ideology in obstetrics is examined from the following four viewpoints: self-deﬁnition of the medical profession, therapeutic differences
and similarities between male and female physicians, professional view
with regard to women and childbirth, and maternal and infant mortality.
This paper explains that obstetricians increased recognition and prestigeof the profession by moving toward increased specialization and byemphasizing the important role of obstetricians in the birth process andin society at large.
I SELF-DEFINITION OF THE MEDICAL PROFESSION
At the beginning of the twentieth century, there was no clear demarcation between obstetrical specialists and general practitioners who delivered babies as a part of their wider practice. Most physicians, whether
male or female, identiﬁed themselves as general practitioners; in 1928,
they comprised three-fourths of the profession.8 William Ray Arneyargues that, with a weak boundary, it was almost inevitable that debates
about the ultimate form of the profession occurred. One group specializing in obstetrics, led by DeLee, desired that obstetrics would become asuper profession. The other group, led by Williams, desired a more egalitarian profession, which would be responsive to the needs of generalpractitioners.9 Generalists were vulnerable to a concerted campaign
against “unqualiﬁed” practitioners, who were deﬁned as those lacking
either specialty training or membership in a specialty society. As a result,by 1942, less than half of all practicing physicians described themselves
as generalists; this declining trend accelerated in the succeeding decades.10
In 1920, a new journal for specialists, the American Journal of Obstetrics and Gynecology, was founded to replace the ﬁfty-one-year-old
American Journal of Obstetrics and the Diseases of Women. This
marked the formal beginning of the alliance of obstetrics and gynecology, with the promise of expansion into all aspects of womanhood.11 The
ﬁrst volume of the American Journal of Obstetrics and Gynecology included information on the struggle for self-deﬁnition. In his presidential
address at the American Gynecological Society, Robert L. Dickinson

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suggested a four-year program to professionalize the ﬁeld and delineated
its role in medicine. He emphasized the establishment of a technicaljournal, publication of an adequate textbook, certiﬁcation of specialists,training of leaders by developing training facilities, and even encouragement for women to pursue training in obstetrics and gynecology.
“Think of tight lipped surgery with a tender heart,” he stated, imagining
female physicians performing operations.12
The female physicians largely conﬁned themselves to what weretermed as “feminine” specialties, such as the ﬁelds of obstetrics, gynecology, and pediatrics. Factors other than resistance from male professionals were responsible for female physicians being conﬁned to these
specialties, although they occasionally blamed it on sexual discrimination.13 Regina Markell Morantz-Sanchez argues that female practitioners
also gravitated to these specialties because they were conscious of their“special” abilities. They were concerned about the health problems ofwomen and children because they desired to raise the moral tone of thesociety through the improvement of family life.14
While female physicians could be viewed as taking advantage of theirreputed expertise in obstetrics and gynecology, most of the national
specialty societies refused to admit women as members until well after
the creation of the specialty boards during the 1930s.15 For example, theCouncil of the American Gynecological Society discussed whether
women could be elected to fellowship and unanimously recommended
that women were eligible for membership. Lilian K. P. Farrar of
Woman’s Hospital in New York was elected as the ﬁrst woman member of the Society in 1921, but it was only ﬁfty years later in 1971 thatthe second woman, Georgeanna Seegar Jones of Baltimore, was electedto fellowship.16
The ﬁrst thirty years of the twentieth century were crucial for female
physicians; they struggled for self-deﬁnition within a ﬁeld that was rapidly restructuring itself and its social role. Despite the achievements offemale physicians in the late nineteenth century, the ﬁrst few decades of
the twentieth century constituted a difﬁcult period for the progress of
women in medicine. Due to a male backlash and institutional discrimination, fewer women were admitted to medical schools and female
physicians had fewer opportunities for advanced training or scientiﬁc
research. As a result, female physicians lost ground relative to their malecolleagues and possessed neither power nor authority in the professional
community.17

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While professionalization in general created new career choices in“feminine” professions such as nursing and social work, professionalization in medicine constricted women’s activity as physicians andconﬁned their participation to particular specialties that were already
implicitly agreed upon in the nineteenth century. In the early twentiethcentury, when male physicians strove to deﬁne themselves as specialists
in obstetrics, female physicians were excluded from the professional
community, despite their “special” abilities and reputed expertise in the
ﬁeld.
II

THE THERAPEUTIC DIFFERENCES AND SIMILARITIES BETWEEN
MALE AND FEMALE PHYSICIANSHistorians have wondered about the therapeutic differences and similarities between male and female physicians. Studies have revealed thatgender played a small, but not necessarily insigniﬁcant, part in the treatment approach of male and female physicians. In order to determine
whether male and female physicians differed in their treatment toward
women during childbirth, Morantz-Sanchez compared maternity cases
between the female-run New England Hospital from 1873 to 1899 andthe male-run Boston Lying-In from 1887 to 1899.18
According to Morantz-Sanchez, the records and annual reports indicate that the patients of both hospitals were poor; however, the patientsat Boston Lying-In were poorer. Both Boston Lying-In and New England
Hospital normally refused obstetric service to unwed mothers who werebearing their second illegitimate child. However, unlike Boston LyingIn, the ratio of single mothers to married mothers at New England Hospital declined throughout the time period studied. The female physicians
at New England Hospital showed a greater interest in patients who were
amenable to moral reform and in creating a Christian atmosphere forerring women, whereas the male physicians viewed their role in the hospital from a narrower perspective. Morantz-Sanchez suspects that thetraditionalism of the female physicians in this instance could be largely
due to their investment in the Victorian culture that identiﬁed women as
the moral guardians of society.19
Another noticeable difference between the two hospitals was the sheer
amount of information listed on the hospital’s patient charts. According
to Morantz-Sanchez, the records of New England Hospital were consistently more complete. In addition to an account of the actual treatment,

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they provided a greater amount of information with regard to the patient’s medical background and a more detailed indication of her social
status. As Morantz-Sanchez argues, this meticulous record-keeping
revealed not only the self-conscious professionalism typical of female
physicians but also the “leveling” process at work at Boston Lying-In.
The female physicians at New England Hospital attempted to ﬁnd information about their patients and distinguished, at least in their records,
between various levels of poverty. The lack of similar distinctions at
Boston Lying-In implied that poor women treated in an often overcrowded teaching facility might have represented a single category to
the male physicians.20
The standard maternal recuperative period at Boston Lying-In was two
weeks with very slight variation, whereas the New England Hospitalpatients remained under care for a period ranging from four days to threemonths and were, on an average, under medical supervision for one weeklonger than their Boston Lying-In counterparts. This variation could be
attributed not only to individual physical considerations coupled withthe availability of space but also to social considerations. Single mothers
normally remained under medical care for a longer period of time; this
could probably be due to the fact that they had nowhere else to go or
because the female physicians at New England Hospital felt that suchpatients required more of the hospital’s meliorative moral inﬂuence.
With regard to female physicians, Morantz-Sanchez points out that when
determining the duration of stay, the patients’ social situations were considered to have the same weight as their medical variables.21
Statistics revealed no signiﬁcant divergence between the two hospitals with regard to infant mortality or maternal outcome. However, methods of care offered to patients after delivery, particularly with regard toprescriptions for relief, differed between the two hospitals. At Boston
Lying-In, drug prescription was dependent on the physical symptoms.
The female physicians dispensed medication or supportive therapy forless codiﬁable and nonphysical reasons. Everyone received at least “beeftea” and on several occasions, a mild pharmaceutical. While it is possible that most of the Boston Lying-In patients were protected from unnecessary medication, it is also possible that they were virtually ignored after
delivery. The medication policy by New England Hospital implied morepatient-doctor interaction and an alternative ethos concerning the postdelivery needs of women. Morantz-Sanchez argues that if this specula-

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tion is correct, then the female physicians were exhibiting a concept of
professionalism that deemed the supportive therapy to be as importantas the pure technical concern for the patients.22
Another factor under consideration in her study was the relative useof intervention techniques, particularly forceps. According to MorantzSanchez, the data revealed no dramatic difference with regard to the relative willingness of physicians at either hospital to resort to intervention
techniques. In addition, the medical criteria for the use of forceps weresimilar at both hospitals. The labor of women who underwent forceps
deliveries was signiﬁcantly longer than the average; this was probably
because most women were bearing their ﬁrst child. The use of forceps
increased gradually at both hospitals during the last decade of the nineteenth century.23
On the issue of childbed fever, Boston Lying-In had more difﬁculty
controlling puerperal infection than New England Hospital. Prior to theintroduction of successful antiseptic techniques in the Hospital in 1885,
Boston Lying-In had been forced to shut down three times due to epidemics, in contrast to just one case of shutting down for New England
Hospital. More deaths occurred at Boston Lying-In. It is possible that
Boston Lying-In’s comparatively poor record in preventing sepsis
stemmed from the staff’s stubborn reluctance to accept that nurses andphysicians could be the possible sources of infection, whereas female
physicians at New England Hospital were more willing to view themselves as fallible. However, Morantz-Sanchez argues that their divergent
records with regard to the fever might not be related to the sex of thephysicians in charge, but rather to complex and idiosyncratic difﬁculties
relevant to the hospital architecture and ﬁnances, the personalities andexperience of the physicians, and blind luck.24
Morantz-Sanchez concludes that the gender of the physician was important in more subtle ways. Social assumptions inﬂuenced the medical
practices of the male and female physicians, and their attitudes toward
their roles were divergent. The male physicians embraced a more modern
technocratic approach toward their patients, whereas the female physicians continued to cling to traditional holistic orientations. It is certainthat the female physicians were always aware of their gender, and thisinﬂuenced their interests within medicine as well as their affective behavior while caring for patients. It is possible that the female physicians
exhibited a different orientation toward patient care. Morantz-Sanchez

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argues that male and female physicians acted in a similar manner in mosttherapeutic situations; however, the reasons for the action taken werevery different.25
Ellen S. More also draws a comparison between Practitioners’ Society, a women’s medical group in Rochester, New York, and PathologicalSociety, the city’s all-male counterpart, in order to provide some insight
into the character and extent of the ideological and therapeutic differences and similarities between male and female physicians. A comparison between the therapeutic values of the two societies revealed an
overall similarity in their clinical judgment. In the discussion held at the
Pathological Society in 1888 with regard to the complex matter concerning the appropriate use of forceps in obstetrics, the majority was of theopinion that forceps should be used only as a last resort. With regard to
the related question of whether to repair lacerations of the perineum, a
discussion held several years later revealed that most members favored
immediate repair. A similar discussion at the Practitioners’ Society in1900 also showed that the majority was in favor of immediate repair.
With regard to the use of forceps, a survey of sixteen consecutive casesin 1901 indicated no disagreement among male and female physicians.26
The therapeutic similarities convey that the female physicians viewed
themselves as full-ﬂedged medical professionals. Their medical opinions tended to reﬂect professional and scientiﬁc trends. The female
physicians internalized many “male” values. The different orientation
toward patient care and the therapeutic similarities suggest that thefemale physicians struggled to strike a balance between science, professionalism, and their womanhood in the male-dominated medical world.
III

PROFESSIONAL VIEW WITH REGARD TO WOMEN AND
CHILDBIRTH

Medical journals of the late nineteenth and early twentieth centuries
reveal a debate among obstetricians with regard to whether childbirth
was a natural event requiring the obstetrician to allow the natural courseof events or a pathological crisis demanding active and vigorous intervention. The obstetricians openly identiﬁed with what they referred toas the “radical” or the “conservative” position. In the ﬁrst volume of theAmerican Journal of Obstetrics and Gynecology, DeLee argued thatbirth was “a decidedly pathologic process” and that “only a small minority of women escape damage during labor.”27 In his view, “the powers

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of natural labor are dangerous and destructive in many instances to bothmother and child” and “interference by a skilled accoucheur [male midwife] at the proper time can prevent a goodly portion of this danger andmuch of this destruction.”28
The groundwork for intervening in labor was laid by the following
view of radical obstetricians: modern women, at least those who could
afford the services of obstetricians, were weakened by education and thechanging environment and were thus unﬁt for childbirth. DeLee referred
to women of his time as “the nervous inefﬁcient product of modern
civilization,” emphasizing the important role of obstetricians in the birth
process, which modern women could no longer manage without theexpert’s assistance.29 In defense of the widespread use of anesthesia inchildbirth, George Clark Mosher of Kansas City argued that women in
the twentieth century had “by education and environment, developed
into [sic] an extreme type of hypersensitiveness” and therefore felt pain
more acutely.30
Apart from their weakened state, women were portrayed as being quitedemanding of their obstetricians, clamoring for shortened labors andrelief from pain. At the meeting of the American Gynecological Society
in 1921, Brooke M. Anspach of Philadelphia stated that the expectant
mother “grasps quickly at any new plan that will bring on her labor at
the appointed time, that will hurry it along and save her from pain, etc.,
little knowing or weighing the disadvantage to herself or to her baby.”31
DeLee argued that women had learned to seek the expert’s skills andwere willing to pay for these to avoid labor pain.32
Obstetricians insisted that the fear of suffering caused many young
women to escape pregnancy at all costs, even going to the extreme ofhaving a “criminal abortion” to avoid childbirth. When Mosher studied“the statistics of the alarming decrease in the size of the families in thiscountry in the last 40 years and the alarming increase in abortion,” heconcluded that American women desired to escape maternity because
they feared the suffering they had to endure during childbirth.33
Most of the methods of intervention, including anesthesia during laborand cesarean sections, were developed with the stated purpose of relieving these women from the perils and pain. “Many women are ready toundergo the slightly increased risk of cesarean section in order to avoid
the perils and pain of even ordinary labor,” argued DeLee. “I am conﬁdent that if the women were given only a little encouragement in thisdirection, the demand for cesarean section would be overwhelming.”34

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Such assertions created a market for the services of obstetricians among
women who could afford to pay, and helped in establishing the dominance of obstetrical specialists over midwives and general practitioners.
The conservatives opposed this radical intervention in childbirth. At
the annual meeting of the American Gynecological Society in 1921,
Rudolph W. Holmes of Chicago warned that the basic error “that pregnancy and labor are pathologic entities, that childbearing is a disease, asurgical malady which must be terminated by some spectacular procedure” had crept into the obstetric ﬁeld. He believed that “childbearing is
not a disease, is a normal physiologic function.”35 According to Charles
P. Noble, since the ancient times, labor for the majority of women had
been considered as a physiologic process accompanied by a minimum
risk to the mother and the child; therefore, to transform it into a major
surgical procedure was “contrary, not only to logic, but also to common
sense.”36
Some conservatives emphasized the danger of intervening, whileothers expressed the fear that the physicians readily intervened in order
to serve their own interests by shortening the labors and thus saving time.
Anspach argued that “the obstetrician, no matter how conscientious hemay be, is almost tempted to induce labor at set date, administer stimulants for the pains, and adopt manipulative or operative measures toshorten the period of parturition.”37 In his chairman’s address at the Section on Obstetrics, Gynecology and Abdominal Surgery at the Sessionof the American Medical Association in 1926, George Gray Ward of
New York stated that “the fact that some expert obstetricians can moreor less safely hasten labor by operative intervention, thus saving themselves time and shortening the patient’s immediate ordeal, together with
our national tendency to hurry in the rush incident to competitive practice” had been the cause of dangerous shortcuts by the general practitioner and many so-called specialists, which too often led to disastrous
results for both mother and child.38
Despite such criticism of widespread intervention in labor, the activist
ideology has persisted as the dominant ideology of the obstetricians. Its
emergence and the displacement of the less interventionist conservative
stance were inﬂuenced by not only the union of obstetrics with the surgical ﬁeld of gynecology but also the expressed need of the new specialty
to separate itself from the general practitioners. According to Summeyand Hurst, obstetricians felt that “any medical person could assist in adelivery, but only the experienced specialist—the ob/gyn—could inter-

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fere safely and successfully.”39 Although some conservatives challenged
this activism on both economic and safety grounds, Summey and Hurst
argue that “the activist ideology developed during the 1920s served as afoundation during the late 1940s and 1950s for an expansionist view ofthe ob/gyn’s role of caring for women’s entire reproductive system in all
its physical and psychological aspects.”40 The supposed demands ofwomen for shortened labors and painless childbirth were used to justify
the constant search for and use of new methods of intervention in childbirth. The combination of the risks during childbirth and relief from pain
ensured the importance of the obstetricians in the birth process.
IV MATERNAL AND INFANT MORTALITY
The internal advancement of the profession along increasingly active
clinical lines was complicated by intense societal pressure to lower thepersistently high maternal mortality rate. The mortality associated withchildbirth became a matter of public concern in the late nineteenth
century, as health authorities began to systematically record births anddeaths and compile vital statistics. In 1880, the Bureau of Census established a death registration area. The annual collection and publication ofmortality statistics within the registration area was begun in 1900. The
original death registration area included only two states (Massachusetts
and New Jersey). The area had gradually expanded, and by 1933, it
included all forty-eight states. Similarly, a birth registration area wasestablished in 1915, and by 1933, it had gradually expanded to include
all forty-eight states.41
Concern for maternal and infant health began in the late nineteenth
century and led to the foundation of the federal Children’s Bureau in
1912. In 1917, Grace L. Meigs, Director of the Child Hygiene Divisionof the Children’s Bureau, published the ﬁrst study to compare the maternal mortality rate in the United States with those of certain other countries. It was estimated that in 1913, at least 15,000 women died fromcomplications during childbirth in the United States; approximately
7,000 of these women died from childbed fever, a disease that wasproven to be almost entirely preventable, and the remaining 8,000 diedfrom diseases known to be, to a large extent, preventable or curable.
Among women in the age group of ﬁfteen to forty-four years, childbirthcaused more deaths than any diseases, with the exception of tuberculosis. From 1900 to 1913, deaths due to childbirth and childbed fever in

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the United States showed no decrease, although deaths from otherpreventable diseases such as typhoid, diphtheria, and tuberculosis declined during this time. Of the ﬁfteen foreign countries investigated, only
two showed a higher number of deaths due to childbirth than the UnitedStates.42
The high maternal mortality rate roused great interest among physicians in the United States. After this study was made public, physiciansand health ofﬁcials attempted to determine the cause of the high maternal mortality rate in the United States. The conservatives attributed thehigh maternal mortality rate to radical operative interference. In 1925,
at the meeting of the Section of Obstetrics and Gynecology of New York
Academy of Medicine, Austin Flint concluded that a less invasive, moreconservative approach was “the outstanding remedy for the present highmortality.”43 James E. Davis of Ann Arbor found that “where obstetricians are highly trained, elective operative interference has increased
sufﬁciently to neutralize an otherwise descending maternal and infantile
death rate.”44 Admitting the abuse of cesarean section among physicians,
H. J. Stander of the Department of Obstetrics and Gynecology at Cornell
University Medical College and New York Hospital estimated that“close to 2,000 women are unnecessarily sacriﬁced each year due to thisurge to operate.”45
The radicals attributed the high morbidity and mortality rate to reasons such as “lack of aseptic practice and conscience in a large numberof physicians,” “interference in the labor process by men that do notknow how,” and “lack of prenatal care.”46 As Summey and Hurst point
out, there was a considerable amount of interest in prenatal care as a possible solution to the problem since it allowed the profession to continue
to expand rather than to criticize itself and retreat.47 The interest in prenatal care led to the formation of a committee in order to “draw up standards of prenatal care for the use of physicians at clinics and also thoseengaged in private work.”48
Moreover, it was recognized that numerous unnecessary deaths ofmothers took place, and this propelled federal, state, and municipal
health agencies to initiate programs that were intended to reduce the mortality rate. In 1921, the federal government passed the Sheppard-TownerMaternity and Infancy Act for the promotion of the welfare and hygieneof maternity and infancy, providing ﬁnancial help to the states for thepromotion of good prenatal care for all mothers during childbirth. The
American Medical Association and several state medical societies

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opposed the Act since, as George W. Kosmak of New York City argued,
it would “practically take out of the hands of the medical profession thecare of pregnant women and children, and place their observation in thehands of lay persons, not to be solved as a medical but as a sociologicalproblem.”49
In 1925, the American Journal of Obstetrics and Gynecology established a special section called the “Department of Maternal Welfare.” In
its initial announcement, the professional view with regard to government meddling was clearly stated: “Within recent years the specialty oflay activity and even the national government has attempted through theministrations of the Shepard-Towner Act to control or supervise theproblem of so-called ‘better maternity care.’ . . . It cannot be solved
except by a combination of forces, and the direction of these forces
should rest in the medical profession itself.”50 The medical professionals were in fear of being deprived of their control on maternal care.
In contrast, the Children’s Bureau supported the Act on the groundthat it would assist in the elimination of the high maternal and infantmortality rates in the United States. The Act was strongly supported byseveral women’s groups, including the American Medical Women’s
Association.51 Some members of the obstetrical and gynecological societies recognized its inevitability. At the meeting of the Section on
Obstetrics and Gynecology of the New York Academy of Medicine in
1922, Frederick W. Rice argued that when the act would be “carried out
by co-operative action of the States,” it would “be responsible for the
beginning of a decline in the present high mortality rate.”52
However, maternal and infant health did not improve during the1920s; the profession was under considerable public and specialist pressure to create the qualiﬁcation criteria for the practice of obstetrics. The
external pressure to lower the maternal mortality rate and the internalpressure to raise the status of the profession resulted in the establishmentof the American Board of Obstetrics and Gynecology in 1930. The purpose of the board was to certify the specialists in the ﬁeld of obstetrics
and gynecology by virtue of their passing an examination and presenting reports on ﬁfty obstetric or gynecologic cases. The American Board
of Obstetrics and Gynecology was the fourth specialty board to establish itself.53
The development of the prenatal care programs and the professionalization of the ﬁeld could not prevent the maternal mortality problem fromreappearing in the early 1930s. The Public Health Relations Committee

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of the New York Academy of Medicine studied the maternal mortality
in New York City from 1930 to 1932.54 The study concluded that thedeath rate due to puerperal causes had not shown any tendency to decrease over the past twelve years, despite progressive improvement in
the methods of treatment and the increased hospitalization of expectant
mothers. It was estimated that two-thirds of all the deaths studied could
have been prevented if the women had been provided with proper carein all aspects. Certain elements were reviewed as contributory causes ofthe production and maintenance of the persistently high death rate. These
included inadequate and improper prenatal care, high incidence of operative interference during labor, incapacity of the attendants, inadequate
hospital standards, and midwife practice.55
According to Charles R. King, the female physicians were largely
silent about maternal mortality. The female physicians did not voice any
differences that they may have had with the ofﬁcial pronouncements of
the leading obstetricians of the city. They neither had the position nor
the authority to speak up on the expanding professional role of the eliteobstetricians in the city.56 The report by the White House Conference onChild Health and Protection published in 1933 also featured the fact thatthe maternal mortality rate had not declined between 1915 and 1930
despite the increase in the number of hospital deliveries, introduction ofprenatal care, and increased use of aseptic techniques.57 Since the statistics were obtained from a considerably wider area, approximately elevenstates, the impact of this report was even greater than that of the New
York study.58
After the publication of these reports, the maternal mortality problem
received little attention. One reason was the reduction of the maternalmortality rate. Between 1933 and 1940, the national maternal mortality
rate decreased from 61.9 to 37.6 per 10,000 live births.59 However, another reason was that infant mortality became the focus of attention forthe medical community as A. J. Skeel of Cleveland stated that “in recent
years attention has been focused on the baby and its welfare more thanon that of the woman.”60 From a national point of view, the signiﬁcanceof high maternal mortality rate was “found not only in the loss which
this means of the lives of women presumably in their prime, but also in
the far-reaching effect of maternal mortality on the infant death rate.”61
Instead of focusing on the expectant mothers or their reproductive systems, the obstetrical specialists now concentrated their efforts on theinfants, ignoring several needs of the expectant mothers. In an environ-

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ment where the obstetricians strove to minimize their dependence on
women patients in order to acquire status and power in the medical world,
it was not surprising that they emphasized saving the lives of the infants
rather than those of the mothers.
CONCLUSION
By the end of the 1930s, the ﬁeld of obstetrics was ﬁrmly established
as a specialty in American medicine. As obstetrics achieved status as a
specialty within the broader medical profession, the women patients did
not have an important part in childbirth. Arthur H. Bill of Cleveland
asserted that “the part which the patient takes in labor is largely a passive one, consisting chieﬂy of breathing the anesthetic as directed.”62 J.
Wesley Bovee of Washington, DC held that “a patient should be treatedas judgment dictates; that we should act as practitioners of medicine
instead of those who cater to the wishes of their patients.”63 It was not
the women patients but the obstetricians who played an important rolein childbirth.
The obstetricians viewed the obstetrical “case” independently of thepatient. Walter Edmond Levy of the Department of Obstetrics at TouroInﬁrmary and Tulane University in New Orleans admitted that “we areprone to accept each new patient as ‘just one more conﬁnement case,’
and in the rush of our daily routine we seldom stop to individualize thewoman, to classify her, as it were, not only medically but sociologicallyand psychically as well.”64 The obstetricians regarded the womenpatients as mere carriers of the “case.” As Arney points out, the womenpatients were clinical specimens that the obstetricians and medical students could use for teaching, observing, and experimenting, a practicethat continues even today.65
Until the early twentieth century, there was no agreement on what
constituted an obstetrical specialist. Obstetrics lacked recognition andrespect as a specialty and therefore obstetricians struggled to establish
obstetrics as a prestigious specialty, similar to other ﬁelds of medicine.
When the male physicians deﬁned themselves as specialists in obstetrics
and strove to acquire status and power in the medical world, the female
physicians were excluded from the professional community despite their“special” abilities and reputed expertise in the ﬁeld. Although female
physicians were aware of their gender and its inﬂuence on their interests
within the ﬁeld of medicine, they acted in a similar manner as their male86

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colleagues in most therapeutic situations. The female physicians
regarded themselves as medical professionals and internalized many
“male” values in the male-dominated medical world.
The radical obstetricians regarded birth as a pathological process andintervened during childbirth to prevent danger and destruction. They portrayed women as clamoring for shortened labor and relief from pain. The
risk during childbirth and relief from pain ensured the importance ofobstetrical specialists in the birth process. The advancement of the profession was accelerated by societal pressure to lower the high maternalmortality rate. The obstetricians attributed the high maternal mortality
rate to reasons such as lack of prenatal care. Interest in prenatal careallowed the profession to continue to expand. Moreover, pressure tolower the maternal mortality rate resulted in the creation of qualiﬁcation
criteria for the practice of obstetrics. Through this process, obstetrics
gained recognition and respect as a specialty in the medical world andin society at large.
NOTES
1Charlotte G. Borst, “The Professionalization of Obstetrics: Childbirth Becomes a
Medical Specialty,” in Women, Health, and Medicine in America: A Historical Handbook, ed. Rima D. Apple (New Brunswick, N.J.: Rutgers University Press, 1992[1990]),197.
2
Ibid., 198.
3
J. Whitridge Williams, “The Midwife Problem and Medical Education in the UnitedStates,” Transactions of the American Association for Study and Prevention of InfantMortality 2 (1912), 188.
4
Joseph B. DeLee, in Discussion on J. Whitridge Williams, “The Midwife Problem
and Medical Education in the United States,” Transactions of the American Associationfor Study and Prevention of Infant Mortality 2 (1912), 196.
5
Pamela S. Summey and Marsha Hurst, “Ob/Gyn on the Rise: The Evolution ofProfessional Ideology in the Twentieth Century,” Women and Health, part 1, 11–1
(1986): 133–45; part 2, 11–2 (1986): 102–22.
6
Ibid., part 2, 117.
7
Ibid., part 2, 117–18.
8
Ellen S. More, Restoring the Balance: Women Physicians and the Profession of
Medicine, 1850–1995 (Cambridge and London: Harvard University Press, 1999), 96.
9William Ray Arney, Power and Profession of Obstetrics (Chicago: University of
Chicago Press, 1982), 51–53. One historian has identiﬁed Joseph Bolivar DeLee andJohn Whitridge Williams as two “titans” of the twentieth century obstetrics. See D. N.
Danforth, “Contemporary Titans: Joseph Bolivar DeLee and John Whitridge Williams,”
American Journal of Obstetrics and Gynecology 120 (1975): 577–88. See also Judith
Walzer Leavitt, “Joseph B. DeLee and the Practice of Preventive Obstetrics,” American
Journal of Public Health 78–10 (1988): 1353–60; Harold Speert, “Memorable Medical
Mentors: IV. John Whitridge Williams (1866–1931),” Obstetrical and Gynecological
Survey 59–5 (2004): 311–18.

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87

More, Restoring the Balance, 96.
Summey and Hurst, “Ob/Gyn on the Rise,” part 1, 135.
12
Robert L. Dickinson, “A Program for American Gynecology,” American Journalof Obstetrics and Gynecology 1 (1920): 2–10.
13
For the sexual discrimination in medicine, see Mary Roth Walsh, “Doctors Wanted:
No Women Need Apply”: Sexual Barriers in the Medical Profession, 1835–1975 (NewHaven and London: Yale University Press, 1977).
14
Regina Markell Morantz-Sanchez, Sympathy and Science: Women Physicians in
American Medicine (New York: Oxford University Press, 1985), 61–62.
15
More, Restoring the Balance, 55.
16
Edward Stewart Taylor, History of the American Gynecological Society, 1876–
1981, and the American Association of Obstetricians and Gynecologists, 1888–1981 (St.
Louis, Mo.: C. V. Mosby Co., 1985), 28.
17
Morantz-Sanchez, Sympathy and Science, 234; Walsh, “Doctors Wanted: No
Women Need Apply,” 186–225.
18
Morantz-Sanchez, Sympathy and Science, 225. For New England Hospital, see
Virginia G. Drachman, Hospital with a Heart: Women Doctors and the Paradox of
Separatism at the New England Hospital, 1862–1969 (Ithaca, N.Y.: Cornell University
Press, 1984).
19
Morantz-Sanchez, Sympathy and Science, 226–27.
20
Ibid., 227.
21
Ibid., 227–28.
22
Ibid., 228–29.
23
Ibid., 229.
24
Ibid., 229–30.
25
Ibid., 230–31.
26
More, Restoring the Balance, 53
27
Joseph B. DeLee, “The Prophylactic Forceps Operation,” American Journal of Obstetrics and Gynecology 1 (1920), 39–40.
28
Joseph B. DeLee, in Discussion of “Symposium: To What Extent Should Delivery
be Hastened or Assisted by Operative Interference,” American Journal of Obstetrics andGynecology 2 (1921), 299.
29
DeLee, “The Prophylactic Forceps Operation,” 43.
30
George Clark Mosher, “Ten Years of Painless Childbirth,” American Journal of
Obstetrics and Gynecology 3 (1922), 142–43.
31
Brooke M. Ansbach, “The Drudgery of Obstetrics and Its Effect upon the Practiceof the Art, with Some Suggestions for Relief,” American Journal of Obstetrics andGynecology 2 (1921), 246–47.
32
DeLee, in Discussion of “Symposium,” American Journal of Obstetrics and Gynecology 2 (1921), 299.
33
Mosher, “Ten Years of Painless Childbirth,” 143.
34
DeLee, in Discussion of “Symposium,” American Journal of Obstetrics and Gynecology 2 (1921), 299.
35
Rudolph W. Holmes, “The Fads and Fancies of Obstetrics: A Comment on the
Pseudoscientiﬁc Trend of Modern Obstetrics,” American Journal of Obstetrics andGynecology 2 (1921), 233.
36
Charles P. Noble, in Discussion on J. C. Applegate, “Rational Obstetrics from the
Teaching Viewpoint,” American Journal of Obstetrics and Gynecology 7 (1924),
224–25.
37
Ansbach, “The Drudgery of Obstetrics,” 247.
10
11

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George Gray Ward, “Our Obstetric and Gynecologic Responsibilities,” Journal of
the American Medical Association 87–1 (1926), 1.
39
Summey and Hurst, “Ob/Gyn on the Rise,” part 1, 138.
40
Ibid., part 2, 104.
41
Judy Barrett Litoff, American Midwives, 1860 to the Present (Westport, Conn.:
Greenwood Press, 1978), 50–51.
42
Grace L. Meigs, Maternal Mortality from All Conditions Connected with Childbirthin the United States and Certain Other Countries (Washington, D.C.: United States
Department of Labor, Children’s Bureau Publication, No.19, 1917), 24.
43Austin Flint, “Responsibility of the Medical Profession in Further Reducing
Maternal Mortality,” American Journal of Obstetrics and Gynecology 9 (1925), 866.
44James E. Davis, “Pathology of the Reproductive Cycle Based upon over Half aMillion Obstetric Deliveries in Detroit,” American Journal of Obstetrics and Gynecology 27 (1934), 462.
45
H. J. Stander, “Cesarean Section and Its Abuses,” American Journal of Obstetrics
and Gynecology 29 (1935), 560.
46
George Clark Mosher, “Report of the Committee on Maternal Welfare of theAmerican Association of Obstetricians, Gynecologists and Abdominal Surgeons,”
American Journal of Obstetrics and Gynecology 9 (1925), 271.
47
Summey and Hurst, “Ob/Gyn on the Rise,” part 1, 142.
48
Fred L. Adair, “Standards of Prenatal Care: An Outline for the Use of Physicians,”
American Journal of Obstetrics and Gynecology 12 (1926), 415.
49
George W. Kosmak, in Discussion of “Symposium,” American Journal of Obstetrics and Gynecology 2 (1921), 303.
50
George W. Kosmak and Hugo Ehrenfest, “Department of Welfare: Announcement,”
American Journal of Obstetrics and Gynecology 9 (1925), 268.
51
Litoff, American Midwives, 99–100.
52
Frederick W. Rice, “Regarding Recent Efforts to Reduce Mortality in Childbirth,”American Journal of Obstetrics and Gynecology 4 (1922), 265.
53
Summey and Hurst, “Ob/Gyn on the Rise,” part 1, 143.
54
The New York Academy of Medicine, Maternal Mortality in New York City: A Studyof All Puerperal Deaths, 1930–1932 (New York: Commonwealth Fund, 1933).
55
Ibid., 213–16.
56
Charles R. King, “The New York Maternal Mortality Study: A Conﬂict of Professionalization,” Bulletin of the History of Medicine 65 (1991), 498.
57
White House Conference on Child Health and Protection, Fetal, Newborn, andMaternal Morbidity and Mortality: Report of the Subcommittee on Factors and Causesof Fetal, Newborn, and Maternal Morbidity and Mortality (New York: D. AppletonCentury Co., 1933).
58
Richard W. Wertz and Dorothy C. Wertz, Lying-In: A History of Childbirth inAmerica (New York: Free Press, 1977), 161.
59
Harold Speert, Obstetrics and Gynecology in America: A History (Chicago:
American College of Obstetricians and Gynecologists, 1980), 148.
60
A. J. Skeel, “Recent Advances in Our Knowledge of Obstetrics and Their Bearing
on Obstetrics as a Specialty,” American Journal of Obstetrics and Gynecology 9 (1925),
239.
61
Fred L. Adair, “Maternal Mortality: The Risk of Death in Childbirth from All
Diseases Caused by Pregnancy and Conﬁnement,” American Journal of Obstetrics andGynecology 13 (1927), 113.
38

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89

Arthur H. Bill, “The Choice of Methods for Making Labor Easy,” American Journalof Obstetrics and Gynecology 3 (1922), 71.
63
J. Wesley Bovee, in Discussion of “Symposium,” American Journal of Obstetrics
and Gynecology 2 (1921), 304.
64
Walter Edmond Levy, “The Proper Evaluation of the Obstetric Case,” American
Journal of Obstetrics and Gynecology 14 (1927), 84.
65
Arney, Power and Profession of Obstetrics, 59–60.
62