USA

The situation in the USA was quite different. Information became available only from 1900 onwards (Pearl 1921), much later than in Sweden, and there was no public policy to deal with what was not generally recognised as an issue. The debate was dominated by the (successful) attempts by obstetricians to marginalise midwifery (Declercq & Lacroix 1985, Borst 1988, King 1991, Reagan 1995).

Figure 4. The combination of technical and policy environment factors that made early reduction of maternal mortality in certain countries possible, and the obstacles in other countries

Midwives there were a mixed lot, going from the many untrained ‘neighbourhood midwives’ to the few highly trained midwives who were mainly recent European immigrants, but left to fend on their own, without support or supervision, despised and professionally isolated. Midwifery was actively discouraged by the lobby of obstetricians. “To the American obstetrician the midwife was ‘a relic of barbarism’ who must be abolished ... If European countries persisted in employing midwives on a large scale, it only showed how backward Europe was compared to America.” (Loudon 1997).

In Sweden the notion of ‘avoidable maternal death’ had been used since the XVIII^th century and was at the basis of a public policy of midwifery coverage. In the USA this notion was essentially used by doctors for ‘scientific’ attacks on the market share of midwives (Fraser 1998). “Fear of the midwife’s real power, her ability to do the work of obstetrics - translated into a public portrayal of such women as primarily responsible for long labours and puerperal deaths. Physicians, by contrast, associated themselves with painless labour and safe childbirth” (Fraser 1998).

There was evidence that midwifery was a real alternative: where midwives were trained and supervised, as in Newark, they achieved remarkable results: a maternal mortality rate of 150 for midwife deliveries as opposed to 690 for deliveries by physicians (Loudon 1997). Nevertheless, obstetricians were left to effectively block the development of professional midwifery: by the 1920s this had already led to a decreasing pool of midwives in urban areas. In Richmond, for example, the midwife examining board had reduced the number of practising midwives from 105 to 47 in a 3-year period (Fraser 1998) and maternal mortality remained high.

The problem of maternal mortality only came on the policy agenda as a result of the public outcry against differences with Europe, in the early 1930’s. The first enquiries into maternal deaths, in New York in 1930-32 (Llewellyn-Jones 1974), led the New York Times to put the blame for avoidable maternal deaths on doctors (Porges 1985). Still, the medical lobby managed to ensure hegemony of hospital delivery. From the late XIX^th century until today, the de facto policy was to promote institutional delivery by obstetricians. However, without mechanisms to guarantee access or quality standards, this failed to address the problem and actually contributed to mortality through iatrogenesis. The lack of norms and accessibility would only be offset by the Emergency Maternity Care Programme during the 2^nd World-War (Schmidt & Valadian 1969).