A Symposium

[IN the April Atlantic Mrs. Lenore Pelham Friedrich described with admirable candor those factors which made childbearing more of a burden than she felt it had any right to be — the hospital fee and the doctor’s charges, which together she placed at $700, the stupefaction of the anæsthesia, the rigid routine of the hospital, and in general the effort to overdramatize a perfectly normal function. In her article, ‘I Had a Baby,’ she went on to tell of the arrangements she perfected in Switzerland to have her fourth child without anæsthetics and without fuss. The answers to Mrs. Friedrich have been both firm and friendly. We are delighted to present such an interesting cross-section of Atlantic opinion. — THE EDITORS]

I

She had a baby!

To qualify myself as an expert witness — I have had eight babies; all are living, strong and healthy. Generalizing from one’s individual experience is always dangerous, but at least I have had twice as much as Mrs. Friedrich.

First, as to expense. I went to a hospital for each baby — three in fairly large cities, five in very small towns. It never cost much more than a hundred dollars for both doctor and hospital charges. I didn’t always have a private room; if I did, if was because no one else happened to come in for the other bed or beds at the same time. I was always comfortable, always had adequate care.

Perhaps because I knew the charges were reasonable I was not on the lookout for small flaws in service which would have been major irritations if I had been paying a great deal. Mrs. Friedrich refers to ‘millions of women who have babies in their own beds cheerfully and cheaply.’ Unless there is another adult woman in the family to care for the mother and baby (and there seldom is nowadays), or the public maternity services are called upon, it costs as much to have a baby at home as in the hospital. If there are other children, the mother cannot have the peace and rest she needs.

It never occurred to me, certainly, to reduce the cost of a baby by a trip to Europe for its arrival! The scheme has a wild originality that almost endears it to me. I am irresistibly reminded, however, of an aunt who, spring and fall, went to New York to buy her clothes. Things were so much cheaper in New York than in Cleveland, she would tell you. Of course, she had to stay at a hotel for two or three weeks to have the clothes fitted, and as long as she was there she might as well see the new plays and . . . Auntie wasn’t fooling herself, though; whether you voiced your comment or only grinned, she would admit: ‘Well, my dear, I like to come to New York.’

The European aura is only one of several variable factors that seriously damage the scientific value of Mrs. Friedrich’s experiment in childbirth without anaesthesia. After all, if you change five or six of the component parts of an experiment, it just isn’t the same experiment. If she wanted to determine the cosmic liberation of a delivery with complete consciousness, and declare its healing values to the world, she should have arranged all the other elements of the situation to correspond with previous occasions. Otherwise the impartial reader feels obliged to assign some credit for soul stimulation to the charms of Switzerland, lower cost for hospital and doctor, and other differences.

When my first baby was born, I gave myself the anæsthetic. It was in a copper company’s hospital on the Mexican border, in Arizona. There was one doctor, and one nurse to assist him. They gave me the ether cone and I held it to my face. When I got drowsy my hand would fall away; when pain grew stronger again it would rouse me to bring the cone back. I was aware of all that was going on, but dreamy, not in unbearable pain. In the other cases the doctors’ methods have varied, but I have never been in complete unconsciousness (for childbirth) for more than half an hour. It is true that most of these births were some years earlier than those of Mrs. Friedrich’s children, but doctors and nurses of my acquaintance tell me that to ‘recover hours later,’ or to have a child born at noon and the next morning just be able to grasp the fact that it is over, indicates the use of an amount of anaesthetic most extraordinary in any normal case.

Isn’t it possible that the author in these details is —shall we say—heightening her effects?

Now, at long last, let me testify as to the complete experience of childbirth without anæsthesia, for I have had that too. I didn’t intend to, and had no time to dramatize myself or get cosmic about it. The doctor and nurse hadn’t believed my statement that I had babies in practically no time at all, so I was attended by one badly scared student nurse. Her one idea was to delay proceedings until someone else could take responsibility.

My mind was far from exhilaration, free from any realization of the elemental character of our moment. I had to be matter-of-fact, to steady her, to reassure her with definite reminders of how very little she needed to do, after all, to make the baby safe until the doctor finally came. We got through quite successfully.

I am afraid I proclaim myself sister to the clod when I declare that I respected myself no more, felt myself no more a complete personality after that than after any birth when I had joyfully accepted any relief the doctor decreed.

We hardly need experiment personally to find out about unalleviated childbirth. Medical history tells us more than I can read without a shudder about childbirth in the days before anæsthetics. It is comparable to the sufferings of wounded men in the same period. Would anyone propose to-day that men should enlarge and complete their personalities by enduring amputations, or even prosaic settings of broken bones, without the aid of anæsthetics?

Mrs. Friedrich seems to be going back to the ideas of the early opponents of chloroform and ether, who declared that mothers could not feel the same sacred affection for their children born without pain. I hoped we had left far behind this mediæval association of spiritual values with physical mortification.

HELEN H. WHITING

Winchester, Virginia

II

My first child was born in a prosaic Middle Western hospital under the care of a twentieth-century American obstetrician whose methods were as coldly scientific as his eyeglasses. But it was exciting and soul-satisfying, and, unlike the author of a recent Atlantic article, I would unhesitatingly repeat the procedure for my fourth.

We were very young and newly married when the knowledge came that we were to be parents, and we found ourselves elated but a little perplexed and uneasy over the mysterious responsibilities suddenly to be thrust upon us. Wasn’t having a baby very expensive? Didn’t women suffer horribly, sometimes even die? What about the new anæsthetics of which we had heard? How to proceed? Modern obstetrics answered our questions, and the feeling of tremendous happiness and anticipation with which I am looking forward to the birth of my second child in June speaks for the value of my financial, physical, and spiritual experiences.

Our financial problem was the first to be solved reassuringly for us. My husband and I discussed doctors, and decided — partly, I suppose, because we had not long been out of the fold of indulgent families — that the best was none too good. I went to an obstetrician with a splendid reputation, and naturally expected that his fee would be very high. I found to my joy and astonishment that, like most specialists, obstetricians charge on a percentage-of-income basis. My doctor also explained it another way. With people of restricted income he charges a percentage of the amount spent in the hospital.

‘It isn’t consistent,’ said he, ‘to have an expensive room, private day and night nurses for the full time, and all the extra furbelows you can get, and expect the doctor to cut his bill to rock bottom.’ I meekly agreed. It would be possible, he went on, to have ample care but the minimum of luxury in the hospital, and he would charge around $125. This meant a two- or four-bed room, however, and I hesitated. When the time came, I was indulged to the extent of having one of the least expensive private rooms, and private nursing for much longer than was necessary, and the doctor’s bill was only slightly above that figure. This fee included everything: at least fifteen office visits, any house visits necessary, innumerable telephone calls (at all hours of the day and night), complicated laboratory work, delivery, and postnatal care until the baby was six weeks old. We added it up according to the most reasonable rates charged us by doctors for head colds, sprained ankles, and poison ivy, and decided that the obstetrician was, if anything, underpaid. Certainly there was not the faintest suggestion of a ‘fee racket.’

Of course fees and hospital rates vary a great deal in different parts of the country. If one lives in the most expensive metropolitan areas, it is possible to obtain equally good care by going to a younger man, an assistant of one’s chosen obstetrician, who will charge less because of his comparative lack of experience and reputation. But he will be in constant consultation with the older man if anything unusual develops, and in some cases the so-called ‘highpriced specialist’ may actually deliver the baby without the patient’s knowledge.

Certainly it seems unfair to conclude that obstetricians in this country are any less open-minded and realistic about the money problems of their patients than medical men in other fields. In this community, wives of ministers and doctors receive no bills, and wives of professors at the University are given a reduction of from 33 1/3 to 50 per cent of the regular fee. I wonder if this is not also true in Cambridge, Durham, and Palo Alto ? Even if a European specialist were to charge as little as one fourth of the amount we are accustomed to paying, the cost of crossing the ocean to him would, for most of us, defeat the purpose.

One of the reasons we were paying an up-to-date man was that I hoped to be spared pain. Twenty-six years ago, when I was born, my mother endured unnecessary agony for twenty-eight hours in a ‘normal delivery’ without even a whiff of gas. The psychological effect of this experience was to make her fearful of childbirth for some time, and undoubtedly had its reflection in my own early doubts on the subject.

I chose, too, to read during the first months of pregnancy Sigrid Undset’s superb Kristin Lavransdatter, and it took several weeks of rationalization and saying ‘ There, there! ‘ to myself to appreciate one immortal bit for its literary worth alone. However, when I entered the hospital, after months of expert care and advice, I was calm and confident that everything possible would be done to make the delivery easy and safe. And it was.

Nowadays, with the widespread use of anæsthetics, the usual reaction after the birth of a strong, active baby is ‘I’d do it again tomorrow!’ This normal, healthy attitude is one to be encouraged, and one for which the less painful deliveries are responsible.

But it seems there are more scientific reasons for the anæsthetics. I was given two: one of the new drugs during hard labor, and a general anæsthetic at the end. Thus there was no question of ‘enduring the labor and missing the climax,’ for it was mercifully dulled from the first.

The drug administered not only relaxes the body so that the doctor and nature may work together harmoniously, but produces a restful sleep following delivery. Obstetricians have found this an important aid in combating a state of nervous tension that is apt to occur — a tension which too often leads to the dreaded hemorrhage. I found, too, that it really was sleep, and not the usual aftereffect of an anæsthetic. There was no sensation of battling phantoms in a dark, nauseous nightmare until I could finally struggle to consciousness.

The general anæsthetic for the actual birth is given to permit incision and stitches that prevent old-fashioned mutilation. It has been pointed out to me that the delivery of a baby is, under the best modern methods, a surgical process. And if this surgery is performed it reduces the amount of operative ‘repair work’ on women in middle life, from 85 to 90 per cent.

I am a firm believer in the premise that the woman of to-day is a cultural, civilized individual, and that there is no reason why I or anyone else should become an animal for a few hours. Animals themselves have a far from easy time in producing their young, and their maternal mortality rate is just as high as that of human beings. We take anæsthetics for operations not because of the pain alone, but because of the shock to our highly developed nervous systems. The birth of a child causes more of a nervous reaction than many an operation, so it is sensible to assume that we will accept the resources of science in this instance as we unerringly do in others. If one feels that one must lest a cherished theory, it is indeed wise to throw out the new in favor of the archaic with the fourth instead of the first-born. But it hardly proves the hypothesis.

The most completely personal phase of the whole matter of having a baby is its spiritual significance — and I can say wholeheartedly that mine was an unbelievably rich experience. Dulled and anæsthetized I may have been at the time of the actual birth, but the comfort and peace so obtained were a large contributing factor to my happiness and serenity. I remember only the pleasant things — sunshine pouring golden through the case-room window, and the cheerful smile of an old friend among the nurses, which held me as firmly as her hand. How can I feel that I have lost any strengthening enlightenment when I have no fear of an ordeal —only an abiding faith in the safety of my future and that of my baby?

As I was fortunate enough to have had a short labor and no complications with my first child, I should be perfectly willing, as far as pain is concerned, to have the coming one at home without anæsthetics. But, understanding now to some degree why things are done as they are in the hospital, I want the security and comfort that knowledge brings me. I know too that, while no anæsthetic given can completely deaden me to the point where I am not conscious of great momentary triumph, my real feeling of spiritual uplift comes when I see my baby for the first time, and realize the miracle that has been wrought.

The actual delivery is a mechanical, inevitable process over which I have not the slightest control. It is during the nine months of pregnancy when I can build for my child’s life and future by my own care, and in nursing the baby during the first few months of its life, that I am entitled to feel myself a supreme being, and guardian of another soul. That which I achieve is thrilling, not what I endure involuntarily. Those whose agony has been prolonged and exhausting have, they tell me, little or no thought of the miracle of birth at the time. They are so spent that they are hardly conscious of its climax, or are utterly indifferent to it. It is, again, afterwards when the elation comes. It might be well to concentrate less on the strengthening of will power during labor, and to realize that by submitting to the action of anæsthesia we are conserving our physical powers for more important things to come.

Now, lastly, I realize that hospital routine is disagreeable to most people, and I am no exception. It is an annoyance to endure, as are many of the regulations that community life makes necessary. There must be rules for the greatest good of the greatest number. But the vexation of hospital routine shrinks to infinitesimal importance beside the safety of the delivery room. According to medical authorities, the three main causes of maternal mortality are infection, hemorrhage, and toxemia. Infection is no more prevalent in hospital deliveries than in those that take place in homes. It is probably less, since hospitals receive many of the home cases only after serious infection has started.

No one denies that hemorrhages can be more readily controlled in a hospital, and toxemia absolutely cannot be handled at home. For every emergency the hospital is prepared, with equipment, methods, and personal care that cannot be duplicated in a household. Logically no one would choose to have an appendectomy performed on the kitchen table. Why, then, the delivery of a baby, which is, or should be, a surgical procedure?

The crude home methods which are still practised, the fact that deaths from abortion are included in the United States statistics, and the further fact that more inclusive data are here available for people in all walks of life — these are the factors which, taken together, give the United States an apparently alarming mortality rate from childbirth. This rate is being lowered day by day, through campaigns to educate more and more women to the importance of proper prenatal care and scientific delivery, and the establishment of better-trained personnel and more adequate facilities to provide this care.

Cold, hard facts. But everywhere in this country to-day these facts are being translated into sensitive, mobile realities. Turning back the clock is a nostalgic gesture common to young and old alike, but we should be thankful for the present, and for the fact that we can face the future armed with knowledge of which our ancestors could only dream — thankful that most of the young women of to-day approach their greatest experience with joyous confidence born of this knowledge.

HELEN WALCOTT MCKENZIE

Winnetka, Illinois

III

The wind was bitterly cold for the first of April. After a walk down the street and back we were content to consider that our afternoon airing and go indoors. This meant a whole hour with no specific chore, so I picked tip the April Atlantic and settled myself comfortably on the sofa. The two little girls, aged eighteen months and three years, spent the time alternately climbing over me, mauling the cat, and playing nicely together. A glance at the title, ‘I Had a Baby,’ aroused my curiosity — what could be said on that subject to be of universal interest? Finishing the article, I remarked to my cousin, ‘If I could write I’d be tempted to have my say about this baby business’ — and my surprise was great when he, a newspaper editor for many years, calmly replied, ‘Why don’t you?’

To begin with, if any subject is down my alley this should be. I have had many babies, but only two did I carry proudly home from the hospital as my own. The others, however, I had just as literally, for with each moan the mother made I suffered intently, if silently. When we were quite young — nurses in training — we used to shake our heads outside the patient’s door and utter the one solemn word—‘Never!’ When, however, the patient smiled cheerfully the next day, said there was nothing to it, and even made plans for future additions to the family, we were a little bewildered. We v7cre probably a shade resentful, too, that we were not able to forget the yesterday’s anguish so quickly. Soon we learned that this sudden forgetfulness is another of nature’s caprices.

Some of the older obstetricians in our Canadian hospital had ideas about the use of an anaesthetic. Their mothers had managed without it and it was not necessary for a normal delivery, and so forth. We nurses did not think of this as an aid to character building, but rather as an unnecessary cruelty. The same type of doctor would allow a patient to spend a restless night in pain because he prescribed a sedative only for extreme pain.

Later, when I was far North at a medical mission, I saw the native women having their babies silently in the natural, grim way without anæsthesia. They were a stoic people of AngloSaxon stock. We used to marvel at their fortitude and tried to explain their difference. Our final conclusion was that their nervous systems were not the same as those of the people we had known. Neither did they ever register any great joy or enthusiasm for the new baby.

In all these anæsthesia-free cases not once do I remember hearing of an afterfeeling of ecstasy.

Shortly after my return to the United States I married an American. We were all struggling along at that time, adjusting ourselves to small salaries and creating a new sense of values. We hadn’t planned on having a baby so soon. Nevertheless we were greatly pleased, for we both knew that we could wait indefinitely for an opportune time or the financial position to justify our deliberately having a baby.

Next there was the expense problem to consider. Some young women we knew had worked after marriage and used their hard-earned savings having a baby in the grand manner (with a high-priced obstetrician, private room, special nurses, and so forth). The thought of sickness after the baby arrived was too terrifying. No! Our small savings must be reserved for a much greater emergency. One day I happened to read in a newspaper about a clinic which was connected with a small private hospital. It sounded like a fairly attractive proposition. I had always admired this efficient, pleasant hospital, so I carefully clipped out the article and then and there made my decision. Since I am a fairly determined female, no one had the courage to argue the point very much. Every once in a while some relative would murmur, ‘I don’t like tins clinic business.’ Thereupon I would point out that this clinic was different from those connected with the large city hospitals, and once more produced my newspaper clipping. With their own eyes they could read the words: ‘For the white-collar class living on small salaries.’ There could be no denying we belonged in that category.

Once a month thereafter I went over for an examination and to leave a deposit of five or ten dollars. (The bill was to be paid before entering the hospital.) The house doctor, a Westerner, was competent and inspired confidence, for all his apparent breeziness of manner. And, somehow, even in a clinic he was able to make one feel like an individual. Later I developed edema. The doctor ordered rest in bed, but an unaccountable energy seemed to possess me —a sort of primitive instinct to get everything in readiness that drove me to weird things such as putting up extra shelves in the closet.

Then one day, after examining me, that doctor said I should have to be admitted to the hospital that afternoon. I gasped! ‘But to-morrow is Thanksgiving and next Sunday is my husband’s birthday!’ He grinned and answered, ‘Well, come back prepared to stay next Monday.’ I am still grateful for his lack of firmness. The following Monday I began to see hospital life from a new slant. For the first time in my life I was the patient.

Doctors and nurses have the reputation of being exacting and none too patient when sick. Being a ward patient, I did not expect all the small comforts and was determined not to fuss. Soon I realized this determination on my part was unnecessary, for there was really nothing to fuss about. The ward consisted of eight cubicles. We could not see or be seen by the other patients, and when the curtain was drawn it was much like a small room. The medical and nursing care was fine, and our trays were exactly the same as those served to semi-private patients. All this, though, was relatively unimportant. The important thing was to leave the hospital in perfect physical condition, with a perfectly well baby and no staggering debts.

Knowing all the stages of labor, from my secondhand experiences, I faced the ordeal ahead of me with great trepidation. Would it be as terrific as it seemed? I firmly resolved not to make loud noises or to be a pest to the doctor and nurses. The details of that long, terrible night have grown dim, but I do remember that not one ray of comfort could I get out of any of the thoughts flashing through my mind. Husband, home, dainty baby clothes — even the thought of the new baby brought no solace. It was just a matter of waiting and watching the clock — asking the nurse over and over, ‘What time is it now?’ — waiting, waiting for the doctor’s next visit and listening intently to his every word. The hours dragged by, and finally the longawaited words came: ‘All right, we can take you in now.’ What relief! These efficient people were taking complete charge. I breathed in the gas, thankful to be spared the consciousness of the next hour.

In ten days’ time we took our small daughter home. Her daddy proudly carried her, balanced like an egg on his arm. All the time in hospital he had had to content himself with seeing her through the glass window and listening to my daily descriptions. But he could see the wisdom of this strict rule, so he accepted it, as most people do, without much protest. We sometimes spoke of our daughter as ‘our bargain baby.’ Her total cost had been seventy-five dollars.

When our second child was imminent we did not have to count our pennies quite so carefully. This time we could afford a semi-private room and our own doctor. But a deep sense of gratitude made me cling to the hope of having the same one I had had before. We knew his term as house doctor was about up and wondered if he had decided to go into private practice in our city. One afternoon we drove over to see him and asked our eager question. He was sorry, but he and his wife wore leaving for his home city in Utah. A wistful look came over his face as he said, ‘I want to see some worth-while trees. I couldn’t stand living so close to city pavements all the time.’ He advised me to have his predecessor as house doctor, who was now practising in our neighborhood. We wished each other luck and said our good-byes.

The new doctor took charge and everything went along nicely. This time, however, there was no long night of waiting. My husband had to telephone the doctor, get the car out of a none-too-near garage, and bring a relative to stay with our little girl. The result was a John Gilpin drive to the hospital. Fortunately there was no traffic, and we sneaked through a couple of red lights. The delivery room was soon in a state of busy confusion. My doctor had not arrived. The anaesthetist was about to administer the gas and I knew this was to retard activity until the doctor came. It didn’t matter. These efficient people knew what they were doing, and my responsibility was at an end. I regained consciousness to hear the nurse saying cheerfully, ‘It’s a girl.’

This time the doctor’s fee was $125, which included all prenatal visits and monthly care of the baby for the first six months. I have forgotten the exact amount of the hospital bill, but I know the total cost for doctor and hospital came to less than $200.

Probably if we had five or six more children I could gradually bring myself to doing something heroic. But our family is complete, and I, for one, am quite well satisfied with the present-day American methods.

SARAH M. PRIVETTE

Brooklyn, New York

IV

I am moved to attempt a refutation of the general impression created by Mrs. Friedrich’s article ’I Had a Baby.’ It bears out beautifully the accusations made against the medical profession by governmental publicity within the past two or three years, and gives a damning and totally erroneous impression of the practice of obstetrics in this country as a whole.

The trouble with Mrs. Friedrich and her associates is that they have been buying their obstetrics as they do their cosmetics; they insist upon well-advertised products done up in slick packages — nothing ‘inferior’ will do. If they get a few cents’ worth of product and a lot of package they should not consider themselves cheated; they have been paying for the privilege of having things done ‘in the mode.’

Being a very loyal American, in a mild way, it burns me up to have one of our finest magazines spread the mistaken notion that to have a baby in the pleasant and desirable way described by Mrs. Friedrich one must go to Europe. I suggest that in preparation for her next delivery she join a band of tourists and see America first. She would have to go no farther than our own Middle West to find countless places that offer all the advantages she found with such heartfelt satisfaction in Switzerland — except the scenery. Her window might look out upon cornfields here; but a cornfield may be a pleasant sight, especially if there is a hillside covered with shocks of ripe grain, glinting in the sun, behind it.

This is a town of about eight thousand, the county seat. Our people are predominantly rural, of course; most of us are farmers, or people who cater to the farmers in a business or professional way. And this is the way we have our babies: —

While many women are still delivered in their homes, most of those who can afford it go to the hospital. We have a new, well-equipped, small county hospital. The average stay in the hospital for an obstetrical case is ten days. The maximum hospital charge for mother and baby for this time is sixty-five dollars; if a patient is willing to stay in a fourbed ward the charge is forty-five dollars. This, of course, does not include special nurses. A special nurse is optional with the patient; most obstetrical patients do not have them.

The obstetrician receives a maximum of fifty dollars for an uncomplicated first delivery, a maximum of thirty-five dollars for an uncomplicated multipara. The patient will have advice as to general prenatal care, and numerous blood-pressure readings and urinalyses, careful physical examinations, and the privilege of consulting her obstetrician at any time throughout pregnancy for any special reason. All this is included in his fee; it is not extra. A quotation of such prices would probably confirm Mrs. Friedrich’s belief that none of these village doctors could be worth her risking. A word, then, as to who they are. Some of them were trained at our own state university. Others doing obstetrics in this county are graduates of Rush, Northwestern, Philadelphia, Johns Hopkins, and Washington University. Some of them are members of that distinguished body, the American College of Surgeons—and Mrs. Friedrich’s own $250-dollar obstetrician can have no higher scientific rating than this. It is a common but mistaken idea that only men who could not make good in a city ever go to the country to practise. There are various reasons for men’s preferring to practise in a rural community. Some come because they like the rural habit of living; others come because it offers a clean, pleasant, wholesome place in which to bring up a family; others, because in a place like this it is a little easier to maintain high professional standards.

I am in sympathy with Mrs. Friedrich’s desire to get along without anæsthesia; two of my own three children were born at our local hospital without it. But we have all the accepted types of anæsthesia at hand. We allow judgment and preference to determine such things here, not routine.

FAYE CASHATT LEWIS, M. D.

Webster City, Iowa

(A number of readers were, of course, in partial or complete agreement with Mrs. Friedrich. A statement reaffirming their point of view will be found in the Contributors’ Column of this issue. — THE EDITORS)