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Here is the transcript of Larry J. Gordon, MS, MPH presenting the American Public Health Association‘s annual Martha Mae Eliot Award to Kitty Ernst and her acceptance speech. In this speech, she refers to a cement truck. In the year prior to this award, she was in a nearly fatal accident when a cement truck hit her compact car as she was returning home after a home birth, one winter morning. Getting to the stage was not a quick effort for her.

Larry J. Gordon, MS, MPH:

Thank you very much, Carl. And good afternoon ladies and gentlemen. presenting this award is one of the very pleasant duties and opportunities that the president of your association has each year and I’m sure pleased to have that opportunity today and to visit with the recipient during our luncheon today.

The American Public Health Association’s annual Martha Mae Eliot Award honors exceptional and unusual achievement in the field of maternal and child health. It is awarded this year to Eunice Katherine ‘Kitty’ Macdonald Ernst. I was thinking of our piper yesterday as I read the name Macdonald, a leader in the nurse-midwife movement, the United States and an inspiration to her colleagues and students who collectively provide innovative care to childbearing families.

Nurse-midwifery in the United States began in 1925 in the mountains of Kentucky, with the establishment of the Frontier Nursing Service (FNS) which provided maternal and infant health care to rural Appalachian families who were isolated from traditional medical care facilities. Likewise, its early counterpart, the Maternity Center Association in New York City was organized in 1931, offering the first American nurse-midwifery educational program for professionals in this country, while also providing health services to inner city childbearing women. Both of these pioneering programs are still providing high-quality, obstetric and infant care to families in their regions.

Kitty Ernst is a product of that professional training and work environment, having served both of these organizations during her professional career. She, and many others like her, are responsible for the tremendous growth of nurse-midwifery in this country over the past 56 years, which by the end of the 1970s had expanded to a total of 21 basic nurse-midwifery educational programs. Over a period of three decades, Kitty Ernst has made significant contributions to public health, both at the intimate level in providing services to individual child childbearing families, and at the macro level through the maternal health care delivery systems she has designed and implemented.

Inherent in her work experiences and achievements is a rare combination of attributes that are the hallmark of the role model: dedication, vision, personal warmth, and humility. Her dedication is evident in her clinical work, and service and education at the Maternity Center Association and the Columbia University School of Nursing. She has also devoted countless volunteer hours on behalf of the American College of Nurse-Midwives, which has benefited from her years of service on various committees and her leadership as president in 1962 to 1963.

Her vision as reflected in the innovative health care delivery system she designed, always focusing on those being served instead of those who provide the services. She has implemented this vision in her field work as a consultant to the Maternity Center Association, developing alternative birthing centers in various states and initiating hospital midwifery services where they were not previously existing.

At the present time, she is at work on the support network for birth centers. Her personal warmth and humility sprang from a deep regard for the human needs and values of individuals, whether they are her patients or her colleagues. Her time and resources are always available to those who seek them and her willingness to listen to others and learn from their experience generates a rapport that is a vital ingredient in human relationships.

Not wanting to perpetuate the failures of the medical system, she is a creative nurse-midwife and a wise teacher with a strong commitment to the self-help/ self-care concept of prenatal education. She has authored numerous articles on the subject of nurse-midwifery, and the titles of some of her articles give one a sense of the direction and professional pursuits of the woman we honor here today. Some examples of her contributions to the literature will illustrate what I mean. One called “On the Spot Training for the Unprepared Woman in Labor” and another “Maternity care: an Attempt at an Alternative” and another “A Childbearing Center,” and “Tomorrow’s Child,” and most recently, one called “And Gently Lead Those Who Are With Young.”

The American Public Health Association recognizes the significant contributions that Kitty Ernst has made to the profession of Midwifery, and to the growing use of certified nurse-midwives as part of the team providing care to pregnant women and their infants. We’re extremely pleased to present the 1981 Martha May Elliott Award with a plaque and check to Kitty Ernst. Kitty…

Kitty Ernst:

Thank you Hank Meyer [signer on the award check]. We can cash this later. I’d like to read the card that came with this rose. Best wishes from your colleagues in the public health nursing section of the APHA. We are very proud of your achievements. And I’m proud to be a nurse. … If you’re finished now we’ll get on with this.

They told me I could speak for 15 minutes. I never once pass up an opportunity to make a few points. I prepared about 50 pages here today. Actually, I was a little bit nervous about, um, accepting this award. And one of my children said to me, “Oh Mom, don’t worry about it. Once you get hit by a cement truck, you can take care of anything.”

I’m pleased to be able to accept the award. Not just for myself, but for all the people who are responsible for bringing me to this point in time. It has been said that we all stand on the shoulders of others. And there have been some pretty outstanding women who have contributed to the construction of my life.

• My mother, who raised all nine of us to be independent in thought, confidence in action, and courageous in spirit. She was a woman, for example, who during World War II, gave more gallons of blood and more hours as a nurse’s aide to the American Red Cross than anyone else in our community. She first taught me that volunteerism was for everyone, not just for the wealthy.
• The school nurse, who in second grade caused me to covet her navy blue cape with the red lining.
• Mary Breckenridge, who at age 44, when I thought everyone was over the hill, pioneered one of the earliest and most effective systems of regionalized healthcare, reaching from the most remote mountain home, the center of all primary care, in case you’ve forgotten that, to the largest acute medical care centers of the bluegrass. She and the Frontier Nursing Service taught me the subtle, but critical differences, the subtle, but critical differences between midwifery and obstetrics.
• Hattie Hemschemeyer of Maternity Center Association in New York, who had a vision for nurse-midwifery in America and prodded young midwives to prepare themselves to implement it.
• And last but not least, the many mothers with whom I have worked to bring the desires of the heart of all childbearing families closer to a full understanding of the profound privilege of parenthood.

Most of what we know we have learned from parents. And what we know is that childbearing families of today are seeking a system of maternity care that is measured by the intellect, but controlled by the heart. I have been a nurse-midwife for three decades, as has been stated.

Actually, I didn’t plan to be a nurse-midwife. I went to the Kentucky mountains to ride horseback. I came out of the mountains with a crystal clear understanding of the differences between giving birth and being delivered. That was taught to me by independent, clear thinking, courageous mountain women in the eloquent simplicity of their humble surroundings.

One advantage to having survived for three decades is that one begins to appreciate the circular patterns of evolution.

In the first decade of my life as a nurse-midwife whenever anyone asked, “And what do you do?” I replied, “I am a nurse-midwife.” And they said, “you’re what?!” “A nurse-midwife.” “I didn’t know we had any of them left.” But I refused to be intimidated by such a response and seized the opportunity to educate the gathering to nurse-midwifery.

In the second decade, there was a certain curiosity about nurse-midwifery, but also considerable confusion. Obstetricians wanted us to change the name to Obstetrical Assistants, so that the public would accept us. A lot of physicians had trouble accepting the name that had been so greatly maligned 50 years before when organized medicine decided that the way to clean up the care system was to get rid of the midwife. But physicians weren’t the only ones confused. About that time an artist-friend of mine, invited me to a cocktail party in his New York studio. And on my arrival, he said, “Wait a minute, wait a minute, everybody. Here’s my good friend Kitty Macdonald. And she’s a wet nurse.” I still refused to be intimidated by such confusion and seized the opportunity to educate the gallery to midwifery, La Leche League, and the benefits of breastfeeding.

In the third decade, a lot of forces began to converge in the arena of maternity care. Parents were learning that not only was escape from labor, through analgesia and anesthesia, not in the best interest of themselves or their babies, if they could avoid it, but that the experience of childbirth could for the majority of couples be a high point in their lives. Organized obstetrics drafted a joint statement for a team approach to care and acknowledged for the first time the nurse-midwife is a member of that team. What has been referred to as the Quiet Revolution was underway.

Now I believe that we’re all aware of the movement in maternity care today. I think everyone feels the pressure for change in the marketplace. Now, I believe we face the real challenge.

How do we keep what is good in the present system while we shed the unnecessary or even harmful parts, as we move forward into new understanding? How do we bring together the interests of those who now have a monopoly on the maternity care dollar (I didn’t intend to pause that long there.) with those who should be included in sharing that dollar? And how do we keep childbearing families from being caught in the crunch? How do we negotiate these components into a system that will continue to move forward to a comprehensive maternity care for all, for all childbearing families?

Every day that we delay, we lose. Our delay has already created a desperation in an increasing number of childbearing families. I say desperation, because their experience won’t wait. Their hopes and aspirations for the most part derived from long and serious investigation of both intellect and heart, careful weighing of benefits and hazards — their experience cannot wait for professions, politics, products, profits, process, or policies to change.

Today, a small but significant number of parents are taking the responsibility of the management of care during pregnancy and birth into their own hands. They are making demands on the system, which if unmet by the system, they manage on their own with whatever help they can get. This is viewed by some to be very bad, even to the point of being declared maternal trauma and child abuse. Yet, all to whom we have spoken around the world, with whom we have worked across the nation, from whom we have learned in developing obstetrically safe and personally satisfying services, the absolute opposite is true.

Universally, parents and the providers who have worked with them to take more responsibility for making their own decisions about pregnancy, birth, and parenting, speak in terms of greater knowledge, deeper understanding, profound experiences, intense positive interactions, accomplishment, achievement, acceptance, miracles, unifying forces at work, a sense of family. How can institutions and professions have such a dim view of birth that occurs outside of their setting and control, while those who are participating in it report such exhilarating, light-filled experiences?

Could it be that we are missing something? We have before. One of my most negative recollections in my experience as a nurse-midwife is of the mothers who, refusing to have their boy children circumcised, I forced to force back the foreskin on their little penises a day or so after birth — all in the high and mighty name of cleanliness, science, or whatever. They knew better than I, because most of them didn’t continue the procedure. But I, in the name of good care, intimidated them into allowing me to teach them to do it. And now we know that wasn’t right at all. (To me, if for no other reason, – missed a page.) Perhaps we should seize this opportunity to correct some of the errors of the past.

There is no real evidence that the place of birth in and of itself is a factor contributing to higher morbidity and mortality. Other factors such as unattended and uncared for pregnancy and birth, socio economic forces, and access and availability of medical care when needed are proven factors. We moved all birth into the disease-oriented setting of the hospital for the sake of the minority of women who might become obstetrically complicated before we understood that malnutrition, multiparity, diseases incidental to pregnancy, genetic disorders and physiological differences were the main contributors — not the place of birth.

We made this movement without ever studying the home as a place of birth. And we created new problems. Iatrogenic and nosocomial are new words in our vocabulary. Could it be that we should seize this opportunity to go with these few parents who are opting for alternative styles of maternity care and study the human species in its natural habitat? It amazes me that we are threatened, rather than thrilled, that some young people today are viewing birth as a healthy normal life experience, rather than a disease-oriented medical event. Are we overlooking the opportunity of this century to study human reproductive behavior, physiology, and process without the variables inherent to the acute care setting?

To me, if for no other reason, we should be interested in home birth and birth centers for reasons of science.

In every other species known to man, naturalists of all disciplines go to extraordinary lengths to observe, not interfere but observe, reproduction of organisms from snails to elephants in their natural habitat. And many of these studies are federally funded. Yet the human species has never been so observed. In the name of science and the need for standardization, we have interfered with such delicate dynamics as maternal-newborn attachment. Even when we discovered it, we immediately commercialized it, and pedaled it, before we understood it. We still don’t understand the dynamic properly. And we haven’t begun to ponder the ramifications of interfering with it for three generations.

If we had kept on, we might have lost it forever. It is no wonder parents are in protest. They understood. Every woman who ever asked or reached out for her baby at birth, and was denied and intimidated by those who cared for her and knew so much about what was right. She understood that something died within her at that moment. Doctors Kennell and Klaus under great stress and harassment from their colleagues dared to look — look objectively and describe that consistent human attachment behavior, we now pedal as a commodity called bonding.

What else do we not understand? We don’t understand labor. All the scientific principles of observation have been applied in a setting foreign and often threatening, therefore, altering the physiology of the species. It is possible that all the measurements of the intellect, like labor curves are wrong. And therefore, that all our textbooks would be revised if we could study the human species in its natural habitat.

Now, it would seem that if we accept that the professionals need to get their act together, and if we accept that the place of birth is not really the issue. (I don’t think we’re really ready to accept that yet, but we’ll state it anyway.) If we accept that we really don’t understand from the perspective of the naturalist, human behavior and physiology in the process of reproduction and we need to study it. If we understand all these things, then we should be able to implement change and deal with it as it evolves, right? Wrong.

(in maternity care) If maternity care could be measured by the intellect and controlled by the heart, make no mistake in the final analysis, in the American marketplace, it moves on the dollar. The control of the healthcare dollar is a very complex matter. There are more vested interests attached to that dollar than we could possibly even enumerate here today, let alone discuss it.

We have a peephole view of this complexity in Pennsylvania. You may know the Amish and Mennonite people for the most part pay cash. They shop around for their maternity care the same way they do for their mules. Both are viewed as vehicles of service. They are rarely denied the reduction they often haggle for because the five or six hundred dollar bills they lay on the counter can be counted on. Payment through third party carriers, however, the great middlemen of healthcare is an entirely different matter. A host of lawyers, legislators, medical interest groups, nursing interest groups, whoever, make judgments on your worth, your eligibility, your connections, and whatever else is viewed as necessary to pay for the services that you have already satisfactorily rendered to subscribers.

So although change is almost always presented within a process of simple evolution, it is never simple. It is never a single faceted activity. It is, however, frozen, forced, or facilitated by those in control. We, the providers, the planners, the protectors of the public health and welfare, in short the professionals, we share to some extent, the control that has the power to freeze the changes being explored — changes that hold the promise of humanistic principles of care needed to control the temptation to technologicalize (that’s a Washingtonian word) this little understood, but definitely profound human experience.

We have the power, for now at least, to force the masses of childbearing families to accept our mumble jumble, whether it relates to pushing back a foreskin of putting on a fetal monitor, or we have the power to facilitate the ushering in of a new era in maternity care, where we counsel rather than control and educate rather than intimidate. This opportunity only comes once every three or four generations.

Can we measure by the intellect, control by the heart, and move ahead with truly open competition for the payment of services? Only our children and our grandchildren will be in a position to judge Thank you.