A Career Spent Turning Childbirth Into A Family Affair

When Hazel M. Avery, frustrated in her ambition to teach the history of sociology by the lack of jobs, arrived at the University of Michigan in 1929 to begin nurse's training, "everyone was all hepped on the idea that obstetrics and child rearing had to be very stylized, scheduled and controlled." It was "culture shock" for a young woman from Montana farm country "where babies were held, rocked, fed when they cried and generally 'spoiled,' where fathers took as much part in the child rearing as they wished and young girls were expected to be able to feed and diaper a baby by the time they were nine and bathe them by the age of 12." She "didn't like it at all," and when she was asked in 1939 to become an instructor of maternity nursing and supervisor of the service, she accepted reluctantly. "But in those days nurses were not so much asked as told. I said to myself, 'Well, I have to try it.' " Last Thursday, Miss Avery ended 41 years of professional service to the U-M Medical Center, its students and patients. After 41 years of "trying," the culture shock tías been reversed. W Now, it's more likely to afflict the students she sends out into the world unaware that "family-centered" obstetrical care is not what is practiced in every other hospital in the land, or patients and medical professionals who come to the U-M from other parts of the country knowing Ml well that it's not. There's no doubt that things were better when Miss Avery began her tenure than they had been in the 19th century when the maternal death rate in U.S. hospitals for "childbed fever" was more than 50 per cent. The introduction of asepsis (the absence of germs) to obstetrical practice had already reduced maternal deaths from the "fever" nearly to zero, and hospital maternity care for middle and upper class women had become common. Still, Miss Avery says, it did not become the rule for all women until the armed forces began to provide hospital coverage for wives of non-commissioned servicemen during World War II. And even for many years after that, she says, perhaps 50 per cent of the women who ■ came to the hospital for delivery had never been seen there before, had never had any prenatal care. And many of these women who were used to having their babies at home, says Miss Avery, hated the hospital, much as she had. Why? V "It wasn't very human. All her controls were striDoed awav." When she took over the maternity service in the old U-M Maternity Hospital, "mothers were in one wing, babies I in another and fathers were at home." There was little contact between mothers and babies; babies were fed on rigid schedules, sometimes just holding a bottle in their mouths without picking them and there was a cubicle called "the bawl room" where the babies being weaned from their 2 a.m. feedings in preparation for going home were allowed to cry it out. The normal hospital stay was 14 days (at a total cost of $40, with $10 refunded if she stayed only 10 days). Women were on complete bed rest for almost the entire period, with some doctors even ordering that the patient,s not be allowed to raise the bed while eáting. - Miss Avery frequeiftíy saw youñg fathers-to-be "sitting in the stairwell, unable to do a thing and drunk as a lord," while their wives screamed and agonized (even though heavily sedated) alone through their labor and delivery. Breastfeeding was a '.'lost art." "Doctors," says Miss Avery, "feel very comfortable writing formulas, but they don't know anything about getting the food into the baby, and they know even less about the breast." While the woman was in the hospital, she was completely dependent on the hospital staff for her own care and the care of the baby. There was little attempt to prepare her for taking over those responsibilities when she went home. Miss Avery's objections to this approach were "not scientific - more humanistic." But she says, in fact, there was no scientific backing for this ! ity, and the more doctors find out about ! the psychological and emotional development of the newborn, the more scientific" the "humanistic" has become. A woman h a v i n g a baby at U-M Women's Hospital today finds a different picture. The majority have had as muchas seven months of prenatal care, during which their physician has discussed the alternatives of breastfeeding and bottle feeding and their chances of succeeding at the former, if they're interested, have i been evaluated. Miss Avery, a self-described "middle of the roader in all things," believes no woman should be coerced into breastfeeding if she doesn't want to; but if she does, the nursing staff is fully-trained to help her get started. For manyyears now, the majority of women have left Women's Hospital süccessfully breastfeeding their babies, bucking a decisive ■ national trend to bottle feeding. She may have taken part in a series I of classes offered by the hospital in prenatal and postnatal care for herself and in infant care, or she may have had a nursing student assigned to her under the Home Visit Program to work with her before and after the baby is bom. Chances are her doctor probably will have informed her of alternative types of delivery and encouraged her to take part, with her husband, in classes on breathing and relaxation exercises for labor and delivery. She will learn that general anaesthesia is now the exception rather than the rule during delivery. And the couple will find that the father-to-be is expected to be with his wife in the labor room and is welcome in the delivery room. At present, Miss Avery says, about 50 per cent gof the husbands remain with their wives during the birth. The woman probably will be out of bed within hours after delivery, and her stay in the hospital probably will be four or five days instead of 14. (Less happily, it will cost between $600 and $700 instead of $40.) When the new Women's Hospital was being built in the late '40s, Miss Avery was unable to sell a complete "rooming in" program (mothers and their babies in the same room), so she settled for a modified approach with a nursery between every two-bed ward. But the if-M's pioneering action carne before public health standards for "roomling in" facilities were established. As a result, Women's Hospital was faced a ifew years ago with the necessity of renovating its facility tó comply with the [standards No one at the hospital could see how the facilities could be adapted to meet the requirements, but Miss Avery jumped in with a suggestion: "Knock out the nurseries between the wards, and put the mothers and the babies in the same room." The solution was gratefully accepted, and now, 30 years after she began her active commitment to family-centered maternity care, Women's Hospital has a f uil "rooming in" program. It includes a central nursery, which the parents are free to enter, where the babies are taken when there are other visitors in the mother's room. There are two special "fathers only" visiting hours during the day when the babies can remain in the room, and the father is free to handle the baby, too. Visiting privileges for other children in j the family have also developed in stages. The first step was allowing the mothers to do down to the lobby of the hospital and visit with their older children there. A new policy permitting children to come up and see the new babies in the nursery was inaugurated after an encounter Miss Avery had down in the lobby with the four-year-old son of one of the obstetrical patients. "The boy'9 father was introducing me, and when he found out who I was, that little fellow kicked me straight in the shins and yelled, 'You've got my baby!' "And indeed I did," says Miss Avery. The major obstacles to many of the innovations of family-centered maternity care, she says, are based on the bugaboo of infection. But she believes past policies have been overstated and inconsistent. "Let's be realistic," she says. ' silly to sa'y that a husband can't visit his ] wife when he slept in the same with her the night before. And if he can visit and he's been at home with the kids, or he's brought them to the hospital lobby, why can't they come upstairs? "As of now, the policy is that children cannot visit mothers in their rooms, but, frankly, it's not because there's a real danger of spreading infection, but because the medical staff would have a nervous breakdown." "Contrary to popular belief," Miss Avery says, "America is a nation of talkers, not of doers." The changes just described did not happen overnight. It has taken all of Miss Avery's 30-some years as supervisor of the maternity service to approach the goal of family-centered obstetrical care that she envisiorfed when she took the post, and she scarcely sees the job as finished. (She foresees thát in the future women will come to the hospital for delivery, spend a few hours in sa recovery room and then return home, with the baby. Her post-partum care and that of the baby would be supervised and carried j out by city nurses and helpers.) More than once over the years, she says, she would attend conferences or workshops about innovations in familycentered care that were all the rage in the professional literature, expecting to find practical guidelines on implementing them, only to find that nobody was actually doing it. And even now, when a review of the literature would suggest that familycentered obstetrics is the "in" thing, miss Avery says that change around the country has been "very spotty." To her own former students who write back distressed that the rest of the world is not like Women's Hospital, she , fLy her own example to offer What are you doing to change it?" she asks. "Just pile in there." While making childbirth more natural and lite it would be at home may seern easy and obvious, Miss Avery points out, it is not that easy to establish in a hosl Pital setting. Each innovation had to be carefuüy planned to make it work, and there were some near catastrophes when good ideas were implemented withonf the necessary preparation Miss Avery may never have labored under the notion that "there was anything sacred about hospital routine, that it took precedence over people," but that was not always the case with the entire staff. She found nurses most resistant to change, "with doctors right behind." In her first years, before early ambulation (the practice of getting women out of bed soon after delivery) and when they were still located in the cramped, inadequate facilities of the old Maternity Hospital, there was little possibility of instituting the more radical changes she desired. She concentrated during that period on teaching, training a new generation of nurses who would fit into her concept of family-centered obstetrics. To emphasize her belief that the nurse's responsibility was to make the new mother independent rather than dependent, she told her students that. if she ever heard a patiënt say, "I want to take you home with me. I don't know what I'll do without you," then the student would get a "D." The medical staff, she said, often backed her "radical" new ideas in theory, especially since she usually had the support of the chief of the service, but rebelled when the implementation upsetl their routines. Her strategy for getting their cooperation was to find one or two doctors who would go along with a new idea, such as permitting fathers in the delivery room, and then let consumer pressure do the rest. "Resistance collapses when patients start saying, 'Dr. So-and-So does it. Why don't you?'" Miss Avery says. When it was necessary, however, she did not hesitate to step where angels feared to tread. When young men were being shipped out during World War II, it was inconceivable to her that they would go off without a chance to even hold their babies. "Without asking anyone's permission, I gowned them and plopped the babies in their arms." Then it was only for the soldiers, but it was the beginning, perhaps, of the major role fathers now play in childbirth at Women's Hospital. Miss Avery says she was "a tough, dem a n d i n g teacher, and I knew I was roundly hated by my students." And she "battled the medical staff very persistently for many things through the years." But the rewards of their ultimate approval of her efforts have come f r o m both students and colleagues. Students have come back after many years to thank her for the lessons she taught. And in 1969 she became the first woman and first non-physician member of the prestigious Norman F. Miller Obstetrics and Gynecology Honor Society. "They finally said that they thougifc what I had done was good."