Controlling Pregnancy Fred Lyman Adair And The Influence Of Eugenics On The Development Of Prenatal Care Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale Medicine[.]
The Birth of Modern Prenatal Care
The development of modern prenatal care in the United States is closely linked to Dr Fred Lyman Adair (1877-1972), who is recognized as a pioneer in the field Before Adair's influence, prenatal care was largely inconsistent and primarily provided by public health nurses in select cities His advocacy transformed prenatal care into a fundamental aspect of obstetrics and raised it to a national priority The expectation that every pregnant woman receives care from a licensed physician, along with the extensive federal policies related to maternal and child health, can be traced back to Adair's innovative vision for pregnancy and childbirth in contemporary America.
Prenatal care did not dominate Adair’s career, though it certainly was its culmination In fact, as demonstrated by the hundreds of articles that Adair published in a number of major
6 Arthur B Hunt, “Every Man’s Legacy: Presidential Address.,” American Journal of Obstetrics and Gynecology 76, no
Adair's interest in prenatal care emerged in 1918, well into his medical career, but understanding his approach requires examining the formative years of his early career The first two decades of the 20th century were pivotal in American medicine, marked by the establishment of modern obstetrics as a recognized specialty, the national infant welfare movement addressing high infant mortality rates, and the rise of eugenics in American science and culture These historical moments are essential for comprehending Adair's contributions to the development of prenatal care as we know it today.
Adair grew up under idyllic circumstances Born in rural Iowa, Adair was the only child of
Dr Lyman Adair, the town physician, and Sarah Jennings Adair, a teacher, shaped his early life filled with memories of farms and games However, it was his relationship with his father, a dedicated professional, that significantly influenced his path Following in his father's footsteps, Adair graduated from Rush Medical College in 1901 at 24 and completed two internships in Chicago Driven by ambition, he chose to leave his father's rural practice in Iowa for Minneapolis, seeking greater career opportunities, where he quickly established a strong reputation.
In 1906, after establishing a private practice in Minneapolis, Fred Lyman Adair was invited by the University of Minnesota to serve as an instructor at the College of Medicine and Surgery.
Adair initially started his career as a generalist but aspired to specialize as the medical field evolved at the turn of the century The rapid growth of medical knowledge and technological advancements led to the emergence of medical specialists, who gained increased prestige despite the absence of formal specialty licensing boards This shift prompted many physicians to narrow their practice In his autobiography, Adair reflected on his father's regrets about potentially specializing in orthopedics, recognizing it as a sign of the impending changes in the medical profession Understanding that specialization was essential for leadership in medicine, Adair embraced this new direction.
Adair initially pursued pediatrics due to his interest in children's health and mentorship from pediatricians, but a lack of openings at the University of Minnesota prompted a shift in focus In 1908, he traveled to Berlin, the hub of medical advancement, to work under Dr Robert Meyer at the Berlin Charité, where he studied cervical erosion healing After returning a year later, he decided to specialize in obstetrical cases and diseases of women.
8 Jay Arthur Myers, Masters of Medicine: An Historical Sketch of the College of Medicine, University of Minnesota, 1999-
9 George Weisz, Divide and Conquer: A Comparative History of Medical Specialization (New York City: Oxford
10 Fred Lyman Adair, The Country Doctor and the Specialist (Adair Award Fund, 1968), 64
11 Weisz, Divide and Conquer: A Comparative History of Medical Specialization, 52-60
12 Adair, 65 continued interest in pediatrics, Adair focused much of his energy on obstetrics, which afforded him a way to indirectly study pediatrics but still establish a promising specialized career
Adair demonstrated remarkable ambition and leadership qualities early in his career He quickly rose to the position of Chief of the Department of Obstetrics and Gynecology at Minneapolis City Hospital In 1913, he was further recognized for his contributions by being promoted to a faculty role and unanimously elected by the medical faculty to join the administrative board.
Dr Adair significantly contributed to the University of Minnesota's School of Medicine, helping it become a leading medical institution in the U.S His exceptional leadership and administrative skills earned him numerous accolades, with colleagues expressing immense confidence in his abilities, leading to his appointment to key committees Nationally recognized for his achievements, Adair was elected to the prestigious American Gynecological Society in 1915 A natural leader with ambition and organizational talent, he later became a strong advocate for prenatal care and founded influential national organizations in obstetrics and gynecology.
Pathologizing Childbirth and the Rise of Obstetrics
Despite Adair’s success in establishing himself as a respected obstetrician, the early 1900s was a tenuous time for the field Adair’s choice of specialty was not a popular one among his
13 Myers, Masters of Medicine: An Historical Sketch of the College of Medicine, University of Minnesota, 1999-1966
In 1909, LeRoy Broun became the only physician in Minneapolis to specialize in obstetrics and gynecology, despite warnings from colleagues about the financial risks associated with this career choice Adair, reflecting on his decision, noted that obstetricians faced significant challenges, including lower financial rewards compared to other medical specialties, as many women preferred midwives over doctors due to high fees Additionally, the lack of support for obstetrics within the medical community meant that medical schools offered minimal training in this area, leaving graduates with little exposure to labor and delivery Consequently, obstetricians often struggled for recognition and respect, unlike their peers in other medical fields.
During Adair's career, the landscape of obstetrics transformed significantly, largely influenced by Dr Joseph Bolivar DeLee, a prominent mentor and advocate for the specialty's dignity DeLee, recognized as a pioneering obstetrician, founded the Chicago Lying-In Hospital in 1895, providing charity care to underprivileged pregnant women while educating medical students As Adair entered the field, DeLee was gaining recognition for his innovative and sometimes controversial techniques, including the prophylactic forceps operation, solidifying his status as a leading figure in obstetrics.
17 Williams, J Whitridge "Medical education and the midwife problem in the United States." Journal of the American
Medical Association 58, no 1 (1912): 1-7 highly invasive procedure that included the use of ether anesthesia followed by episiotomy and delivery by forceps 18
DeLee's campaign for the dignity of obstetrics focused on midwives, whom he viewed as both economic competitors and a source of low esteem for the field He argued that public acceptance of midwives undermined the perceived value of obstetrics, questioning whether obstetricians could attain the same respect as surgeons if midwives were seen as interchangeable DeLee labeled midwives as "a relic of barbarism" and contended that the recognition of obstetrics' dignity by physicians would eliminate the need for midwives His influential writings, supported by colleagues, framed the midwife issue as a significant problem, with even sympathetic voices referring to midwives as a "necessary evil." Historians credit DeLee with contributing to the decline of midwifery in the early twentieth century.
18 Lewis, Carolyn Herbst "The Gospel of Good Obstetrics: Joseph Bolivar DeLee's Vision for Childbirth in the United States." Social History of Medicine 29, no 1 (2015): 112-130
19 Joseph B DeLee, “Operative Obstetrics,” in Obstetrics, vol 7, 10 vols., The Practical Medicine Series (Chicago: The Year Book Publishers, 1914), 154
20 Joseph B DeLee, “Progress Toward Ideal Obstetrics,” The American Journal of Obstetrics and Diseases of Women and
21 George W Kosmak, “Discussion,” The American Journal of Obstetrics and Diseases of Women and Children 76, no 2 (August 1917): 320–21
22 Judy Barrett Litoff, American Midwives: 1860 to Present (Greenwood Press, 1978), 70
DeLee's strong criticism of midwives stemmed from his lack of evidence to support his claims, as he believed that obstetrical techniques were the sole means to reduce childbirth-related mortality and morbidity However, statistical data contradicted his views, showing that maternal and infant mortality rates were often higher among physicians than midwives Historians note that the interventionist practices of physicians not only created new challenges for birthing women but also increased the risks associated with childbirth Additionally, physicians contributed to elevated rates of puerperal fever by transmitting infectious diseases from other patients to mothers.
In "Progress Toward Ideal Obstetrics," DeLee acknowledged the concerning evidence regarding childbirth However, he believed that to advance obstetrics and enhance future childbirth experiences, it was justifiable to sacrifice everything, even human life, in pursuit of the ideal.
DeLee emphasized the necessity of a significant change in the cultural view of labor and delivery to achieve the ideal Before the 20th century, pregnancy and childbirth were regarded as natural physiological processes.
Pregnant women often felt no necessity to consult a physician, and the medical field showed minimal interest in their care To challenge these entrenched beliefs, DeLee took the initiative to promote change In his obstetrics textbook, he emphasized the importance of medical involvement in pregnancy.
Physician-centric Prenatal Care
Prenatal Care at the Intersection of Public Health and Medicine
The 1920s marked a significant turning point in Fred Adair's career as he established himself as a prominent academic obstetrician-gynecologist His tenure at the University of Minnesota culminated in a full professorship in obstetrics and gynecology in 1926 In 1928, Adair succeeded Joseph De Lee as chairman of the Department of Obstetrics at the University of Chicago, a position regarded as one of the most prestigious in the field His achievements in academic medicine solidified his reputation, with colleagues recognizing his influence and contributions to the discipline.
Adair has consistently sought excellence in his profession, striving for the highest standards This drive led him to explore new avenues in public health and policy, where he focused on establishing a national organization and collaborating with policymakers to enhance prenatal care.
Adair's passion for public policy in prenatal care was significantly influenced by his experiences with the American Red Cross during World War I In 1918, he traveled to Paris to assist in establishing a prenatal care program, focusing on investigating the obstetric situation in the city His mission involved visiting mothers in their homes to assess their environmental and social conditions, which deepened his understanding of the challenges they faced.
60 Richard Porter Adair, Some Family Origins of Fred Lyman Adair, M.D., and His Wife Myrtle May Ingalls (Maitland, Florida: Adair Charities, 1970), 52
61 Daniel Marion Shutter, “Biography of Fred Lyman Adair, M D.,” in History of Minneapolis, Gateway to the
In his 1923 report, Adair emphasized the significance of addressing social distress and disease alongside physical ailments during pregnancy and delivery He acknowledged that effective prenatal care must integrate the efforts of both the medical profession and public health agencies, highlighting the importance of socioeconomic factors in ensuring successful outcomes for expectant mothers.
In the United States, collaboration between public health and medicine became increasingly unlikely after World War I, as the antagonism between these interrelated fields intensified Initially, public health emerged in the early 1800s focused on disease prevention through improving living conditions and sanitation, with physicians actively participating in local public health efforts However, the early twentieth century saw the rise of modern bacteriology and germ theory, leading public health workers to adopt measures like quarantines and vaccinations to prevent outbreaks As Hibbert Hill noted in 1913, “The old public health was concerned with the environment, the new is concerned with the individual,” highlighting the shift in focus from environmental factors to recognizing individuals as both victims and sources of illness.
Fred Lyman Adair's article, "The Development of Prenatal Care and Maternal Welfare Work in Paris Under the Children’s Bureau of the American Red Cross," published in the American Journal of Obstetrics and Gynecology in 1920, discusses the evolution of prenatal care and maternal welfare initiatives in Paris, highlighting the significant contributions of the American Red Cross's Children’s Bureau.
63 George Rosen, “The Bacteriological Era and its Aftermath,” in History of Public Health, Revised Expanded Edition (Baltimore: Johns Hopkins University Press, 2015), 169-199
64 Quoted in Amy L Fairchild et al., “The Exodus of Public Health: What History Can Tell Is About the Future,”
The American Journal of Public Health highlights a significant shift in public health that led to the emergence of the "golden age of public health" in the early twentieth century This transformative period, particularly during the first two decades, marked a pivotal evolution in health practices and policies.
The shift towards individual-focused public health interventions was met with resistance from many physicians, who perceived it as an infringement on their medical practices, particularly through mandatory reporting of infectious diseases like tuberculosis Physicians argued that such mandates violated the doctor-patient relationship and viewed the expanding role of government in healthcare as a threat to private practices The emergence of socialized medicine in Europe during the 1910s heightened American physicians' concerns, especially as similar movements, such as the health centers movement, began to gain traction in the United States Progressives advocated for centralized health centers to integrate previously separate services for schoolchildren and mothers and babies.
Despite advocates' assurances that health centers would offer only supplementary services and not supplant private practices, significant resistance from private physicians persisted In reaction to the health centers initiative, the American Medical Association adopted a resolution opposing all types of "state medicine."
65 Kant Patel and Mark E Rushefsky, The Politics of Public Health in the United States (London and New York: Routledge, 2005), 86
66 Paul Starr, “The Boundaries of Public Health,” in The Social Transformation of American Medicine (New York: Basic Books, 1982), 145–79
67 Patel and Rushefsky, The Politics of Public Health in the United States, 87
In the May 27, 1922 issue of the Journal of the American Medical Association, it was noted that funded health programs posed a dual challenge to the medical profession They were perceived as a threat to practitioners' autonomy and were criticized for providing insufficient authority to the medical community.
In the early 1900s, prenatal care emerged primarily as a public health initiative, characterized as "preventative medicine as applied to obstetrics." During this period, preventative health measures were closely associated with public health, while the medical profession was largely focused on treating diseases after they occurred Consequently, physicians perceived their involvement in prenatal care as limited, engaging only when medical abnormalities were present.
Adair's efforts significantly transformed physician attitudes towards prenatal care, leading to its inclusion in the federally-funded maternal and infant health program established by the Sheppard-Towner Act in 1921.
The establishment of the US Children’s Bureau in 1912 marked a significant advancement in public health, particularly in prenatal care, as it prioritized the study of infant mortality under the leadership of its first director, Julia Lathrop.
Lathrop, collaborating with AASPIM members, identified the critical role of prenatal care in reducing maternal and infant mortality, leading to efforts to enhance access to these resources nationwide In 1913, the Bureau released a pamphlet offering women comprehensive guidance on diet, exercise during pregnancy, and childbirth preparation By 1918, Lathrop had proposed the Maternity initiative to further support these efforts.
69 Patel and Rushefsky, The Politics of Public Health in the United States, 87
The Sheppard-Towner Bill aimed to establish maternal and child health services across states with federal funding, proposing a minimum of $5,000 for each state through the Children’s Bureau, matched dollar-for-dollar up to a population-based cap While states would locally design and administer prenatal services, these plans required review and approval from the Federal Board of Maternity and Infant Hygiene, which included key officials such as the head of the Children’s Bureau, the Surgeon General, and the US Commissioner of Education.