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Control of Midwives
Society Transaction s THE NEW YORK OBSTETRICAL SOCIETY MEETING OF MARCH 13, 1923
DR.
RALPH
H.
POMEROY IN THE CHAIR
The meeting was devoted to a discussion of sociologic topics of interest to the specialty of obstetrics and gynecology. The following papers were presented:
1. The Broader .Aspects of Birth Control Propa.ga.nda. from the Itledical Viewpoint, DR. GEORGE W. KosMAK. (For original article, see p. 276.)
2. Prenatal Oa;re as Viewed from the Public Health Standpoint, W. LoBENSTINE. (For original article, see p. 286.)
DR. RALPH
3. Control of Midwives,
DR. HAROLD BAILEY.
(For original article,
see p. 293';) DISCUSSION DR. ROBERT L. DICKINSON.-Dr. Kosmak endorsed both in his previous paper of 1915 and in the present paper, the great need of study of this problem. The National Research Council has deeidad to put $25,000.00 into study of sexlife. After going over a good deal of the literature, I say we know nothing about the normal sex life of the normal woman, basing such knowledge on good clinical wisdom, and it is time we found out something about it. We do not know what the normal, or, let us say, the average practice of the ordinary husband and wife is. We know next to nothing about the efficacy of contraceptives. We have at iast found out a little about the percentage of their use-not through a medical group, but through one of these confounded lay groups that butt into our business and find out something that we need to know. Now, the Cancer Society and one or two of the other tuberculosis groups have tackled medical problems led by medical men. Suppose the obstetrician and gynecologist do the same. The start has been made :for us. The Bureau of Social Hygiene of New York sent out a questionnaire to a thousand intelligent women concerning their sex life. Of these 70 per cent were college and university graduates and many were teachers. All precautions were taken to secure anonymity. The sheets that came back had no names on them. This report of Dr. Katherine Bement Davis finds happiness in marriage reported by 87 per cent. Health after marriage was reported to be as good or better than before marriage in 84 per cent. Those who used contraceptive measures (not abstinence) were 74.11 per cent. The average number of their pregnancies was two and one-half, and onethird of this group were in an age when reasonably they might be expected to have other children. Thus, if this thousand comprises a fair cross section of intelligent American womanhood, the stigma of race suicide can hardly apply, or the fear of the nation dying at the top. The reasons given for the use of these 351
352
THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
measures may be roughly grouped ·as 30 per cent economic and 30 per cent health, and it is noteworthy that the main attack on birth control that it makes for childless marriage, seems to be met by the smallness of the number who took precautions because they wanted no child. These were 3.5 per cent, and this figure includes temporary postponements. The remainder of the thousand, the group who used no preventives, show 29 per cent sterile marriages and a very large proportion of one-child sterility. Now, if we got busy ourselves, what would we dof We would first study the problem and find out what there was to it. We know that contraceptives are generally used. The question is, are they harmful f Are they harmless f Do you knowf I don't know. Are they efficaciousi The social hygiene returns find that with the two most effective measures, the use of the condom and the use of coitus interruptus, the figures (which have not been published) are about 12 per cent failures, but they do not state whether the condom was properly use, tested and lubricated. In other words, no medical details of this study have been made. I£ the antiseptic douche was effective in 76 per cent, we must not know whether a suppository was used before it and so on. The same need holds good with the cervix cup pessary. Now, how should we attack the problemf It should be done by some organization which would study the matter. You .or I would not go into such a thing unless it was representative, unless some of the leading men of the profession went into it. Under those conditions, would you be willing to start a research f It is up to the obstetricians and gynecologists to decide physical harm or harmlessness. Suppose the money to study the literature, to make the nec·essary secretarial and other organization is forthcoming. Suppose that men at the head of alienist work, the leading T. B. men, say, ''For our patients we need the obstetricians to make such a study and to instruct our patients in contraceptive methods, and to sterilize them when necessary." Would you be willing to join such a committee, to help to organize such a com:mitteei That question was put up to me. Now, the need having been shown, and there being no other organization to undertake it, a small group of men have made a tentative outline of what such a thing, should be, and that group is made up of the Director of the Social Hygiene Association, a lead'ing internist, a leading health official, a gynecologist, a prominent nurse, a director of a social agency, (other members are to be added), such work, policies, personnel and procedure to be strictly under medical control. If they are not, we will have nothing to do with it. Dr. Kosroak cannot see the necessity of an office. Well, there has got to be some kind of a secretarial office : there has got to be some kind of a loose organization to start the experiment. Patients must be sent to some place to be distributed, with a history, with a signed paper that such advice is necessary. Such an office would not examine them, but, simply being a bureau of distribution, would refer them to a clinie where such w.ork should be done. Then the office assembles and studies the results, as such a center alone can. Does that scheme appeal to you 7 Is that the way to a ttaek f Is that the way the New York Obstetrical Society should endorse it, or should some Sanger group do itt It has to be one way or the other, I agree with Dr. Kosmak as to the many objectionable ways of the other method or attack on the problem. I do not see any other alternative but for us to guide such a movement to see that it goes slowly, and experimentally, with no publicity, with no general propaganda business, in order to avoid the very things which Dr. Kosmak obiects to. To some .of you, to the leaders, I ha~e been asked to send this proposition in order to see whether you approve of it, whether these bigger clinics in New York would be willing to try out some such scheme as this.
NEW YORK OBSTETRICAL SOCIETY
353
DR. G. W. KOSMAK.-As Mr. Dickinson has well said, this is not a problem that can be dismissed by an evening's discussion. It is something that has agitated the world for centuries, and I do not know that we are going to come S:ny nearer to a definite or a satisfactory conclusion, than the Romans did, but they kept at it until Rome fell, and then somebody else took it up and they fell, and I suppose that some day we will fall with our pr
DR.
RALPH
H.
POMEROY IN THE CHAIR
The meeting was devoted to a discussion of sociologic topics of interest to the specialty of obstetrics and gynecology. The following papers were presented:
1. The Broader .Aspects of Birth Control Propa.ga.nda. from the Itledical Viewpoint, DR. GEORGE W. KosMAK. (For original article, see p. 276.)
2. Prenatal Oa;re as Viewed from the Public Health Standpoint, W. LoBENSTINE. (For original article, see p. 286.)
DR. RALPH
3. Control of Midwives,
DR. HAROLD BAILEY.
(For original article,
see p. 293';) DISCUSSION DR. ROBERT L. DICKINSON.-Dr. Kosmak endorsed both in his previous paper of 1915 and in the present paper, the great need of study of this problem. The National Research Council has deeidad to put $25,000.00 into study of sexlife. After going over a good deal of the literature, I say we know nothing about the normal sex life of the normal woman, basing such knowledge on good clinical wisdom, and it is time we found out something about it. We do not know what the normal, or, let us say, the average practice of the ordinary husband and wife is. We know next to nothing about the efficacy of contraceptives. We have at iast found out a little about the percentage of their use-not through a medical group, but through one of these confounded lay groups that butt into our business and find out something that we need to know. Now, the Cancer Society and one or two of the other tuberculosis groups have tackled medical problems led by medical men. Suppose the obstetrician and gynecologist do the same. The start has been made :for us. The Bureau of Social Hygiene of New York sent out a questionnaire to a thousand intelligent women concerning their sex life. Of these 70 per cent were college and university graduates and many were teachers. All precautions were taken to secure anonymity. The sheets that came back had no names on them. This report of Dr. Katherine Bement Davis finds happiness in marriage reported by 87 per cent. Health after marriage was reported to be as good or better than before marriage in 84 per cent. Those who used contraceptive measures (not abstinence) were 74.11 per cent. The average number of their pregnancies was two and one-half, and onethird of this group were in an age when reasonably they might be expected to have other children. Thus, if this thousand comprises a fair cross section of intelligent American womanhood, the stigma of race suicide can hardly apply, or the fear of the nation dying at the top. The reasons given for the use of these 351
352
THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
measures may be roughly grouped ·as 30 per cent economic and 30 per cent health, and it is noteworthy that the main attack on birth control that it makes for childless marriage, seems to be met by the smallness of the number who took precautions because they wanted no child. These were 3.5 per cent, and this figure includes temporary postponements. The remainder of the thousand, the group who used no preventives, show 29 per cent sterile marriages and a very large proportion of one-child sterility. Now, if we got busy ourselves, what would we dof We would first study the problem and find out what there was to it. We know that contraceptives are generally used. The question is, are they harmful f Are they harmless f Do you knowf I don't know. Are they efficaciousi The social hygiene returns find that with the two most effective measures, the use of the condom and the use of coitus interruptus, the figures (which have not been published) are about 12 per cent failures, but they do not state whether the condom was properly use, tested and lubricated. In other words, no medical details of this study have been made. I£ the antiseptic douche was effective in 76 per cent, we must not know whether a suppository was used before it and so on. The same need holds good with the cervix cup pessary. Now, how should we attack the problemf It should be done by some organization which would study the matter. You .or I would not go into such a thing unless it was representative, unless some of the leading men of the profession went into it. Under those conditions, would you be willing to start a research f It is up to the obstetricians and gynecologists to decide physical harm or harmlessness. Suppose the money to study the literature, to make the nec·essary secretarial and other organization is forthcoming. Suppose that men at the head of alienist work, the leading T. B. men, say, ''For our patients we need the obstetricians to make such a study and to instruct our patients in contraceptive methods, and to sterilize them when necessary." Would you be willing to join such a committee, to help to organize such a com:mitteei That question was put up to me. Now, the need having been shown, and there being no other organization to undertake it, a small group of men have made a tentative outline of what such a thing, should be, and that group is made up of the Director of the Social Hygiene Association, a lead'ing internist, a leading health official, a gynecologist, a prominent nurse, a director of a social agency, (other members are to be added), such work, policies, personnel and procedure to be strictly under medical control. If they are not, we will have nothing to do with it. Dr. Kosroak cannot see the necessity of an office. Well, there has got to be some kind of a secretarial office : there has got to be some kind of a loose organization to start the experiment. Patients must be sent to some place to be distributed, with a history, with a signed paper that such advice is necessary. Such an office would not examine them, but, simply being a bureau of distribution, would refer them to a clinie where such w.ork should be done. Then the office assembles and studies the results, as such a center alone can. Does that scheme appeal to you 7 Is that the way to a ttaek f Is that the way the New York Obstetrical Society should endorse it, or should some Sanger group do itt It has to be one way or the other, I agree with Dr. Kosmak as to the many objectionable ways of the other method or attack on the problem. I do not see any other alternative but for us to guide such a movement to see that it goes slowly, and experimentally, with no publicity, with no general propaganda business, in order to avoid the very things which Dr. Kosmak obiects to. To some .of you, to the leaders, I ha~e been asked to send this proposition in order to see whether you approve of it, whether these bigger clinics in New York would be willing to try out some such scheme as this.
NEW YORK OBSTETRICAL SOCIETY
353
DR. G. W. KOSMAK.-As Mr. Dickinson has well said, this is not a problem that can be dismissed by an evening's discussion. It is something that has agitated the world for centuries, and I do not know that we are going to come S:ny nearer to a definite or a satisfactory conclusion, than the Romans did, but they kept at it until Rome fell, and then somebody else took it up and they fell, and I suppose that some day we will fall with our pr