The Real Story of Twilight Sleep and How it Shaped Obstetrics and Hospital Birth
Francis Carmody was the first American woman after the McClures article to give birth in Freiburg, taking her OB with her. Her first birth experience and lengthy recovery had been traumatic. The delivery in Freiburg of her second child in July 1914 was flawless. Carmody became a tireless advocate of Twilight Sleep, staging huge rallies in stores, squares, churches: “If you women want Twilight Sleep you will have to fight for it, for the mass of doctors are opposed to it.” She and her wealthy attorney husband opened a Twilight Sleep hospital in Brooklyn. Carmody became the face of Twilight Sleep.However, several important factors were forgotten:
1. The successes in Freiburg came from the meticulous procedure refined by Gauss & Kronig. The doctor stayed with the woman from the first dose, even up to 24 hours, doing memory tests every 1/2 hour, increasing or decreasing the amount of scopolamine based on her level of awareness of her surroundings. To shield from overstimulation, women were put in tentlike beds, soothed with dark glasses and ear plugs. Some restraints were used for those who became disoriented. (One in 10 ended with general anesthesia, a fact not recorded by the advocates).Women were required to come to Freiburg a month before their due date so the staff could determine the precise amount of scopolamine that would suit her “individual psychology.”
2. The Freiburg clinic was funded by the State University. Doctors received the same government income, no matter how many babies were delivered. The U.S. doctors were in private practice, with no time to stay with a woman during an entire labor, and with much incentive to increase their patient load. The “real” Twilight Sleep was too time-consuming and impractical.
3. The Freiburg clinic was class-oriented. Wards were divided by “nervous temperament” (upper class) and “women of no great intelligence” (lower class). The wealthy received the lengthy prenatal and postpartum stays, private suites, absolute quiet, constant monitoring, and personalized dosages of medication. Visiting doctors did not always see the “best” but rather the experimental models. What transferred to the U.S. hospitals were the protocols of the “low-class” wards. If doctors did witness the refined treatment, they later adjusted to standardized protocols in order to deal with many more patients.
At the peak of the frenzy, the number of women seeking Twilight Sleep outstripped the number of doctors trained to provide it, and drowned out the medical arguments against it. Gauss had recommended a three-year course of study to master the technique and was appalled by physicians who visited the clinic, observed a few deliveries, and went home declaring themselves Twilight Sleep-trained. American doctors sought shortcuts for busy practices. They gave fixed doses of morphine and scopolamine and turned the labor over to untrained nurses until delivery. Reports from this time period from nurses (and hospital neighbors) documented the “inhuman” use of knee, wrist and elbow shackles to restrain the agitation and terror of screaming, delirious Twilight Sleep women. Some hospitals abandoned the technique despite the demand, citing babies turning blue after birth. A meeting of the Twilight Sleep Association was held in New York in April 1915 to map out a strategy for the continued use of Twilight Sleep, including better training, but still blaming any negative outcomes solely on individual incompetence.
Medicine and Obstetrics
Before the Twilight Sleep phenomenon, Obstetrics received little to no respect as a medical specialty. Birth was considered a normal physiologic process; the belief was that women did not need a doctor with special skills in order to give birth. OBs were laughed at by other doctors for doing “nothing.” Training was minimal, lectures considered “worthless.” Many OBs had seen few births before becoming a “Professor of Obstetrics.” Delivering babies was viewed as the work of ignorant midwives, yet the training for dealing with complications was known to be inadequate. With the advent of Twilight Sleep, obstetrics suddenly became complex.
Despite doctors’ antipathy toward Twilight Sleep and their outrage at women’s demands, Twilight Sleep was an avenue for attention and respect. Every woman desiring Twilight Sleep had to be hospitalized, enhancing the scientific aura surrounding the obstetrician. In 1915 these doctors finally felt they were receiving the “proper appreciation of scientific obstetrics.” Kronig & Gauss had long touted their technique as one requiring virtuoso talent to master and valuable time to administer.
In August 1915 Francis Carmody died giving birth to her third baby and Twilight Sleep crashed. After 15 months, the demand for the “Freiburg Miracle” virtually disappeared.
The organized crusade for Twilight Sleep was short but the change in obstetric practice was dramatic. It changed how OBs were perceived, how they treated birth, and how American women experienced it. It accelerated the trend to hospital birth, where, with newly elevated status, doctors gained control of the birth room. By the 1920s, fewer and fewer women gave birth at home, attended by friends and family.
The Twilight Sleep movement revealed the power of consumers to shape medical practice. Patient demand outstripped supply, forcing inadequately trained clinicians to supply inadequately researched procedures and shortcuts.
The Aftermath and Legacy
Twilight Sleep morphed into different forms and other drugs. The desire for painless childbirth (and belief in its feasibility) led to assembly line, hospital-based programs of heavy sedation. Well into the 1970s most women were anesthetized or asleep, their babies pulled out with forceps. [Especially during the 1950s baby boom, there were simply too many births and not enough doctors].
Birth became a mainstay of hospitals, originally triggered by the promise of Twilight Sleep. Forgotten were the early controversies, feminist demands, negative clinical data. The next public campaign began in 1960, out of concern for the potentially harmful effects of drugs on the infant.