Historical midwives

Midwives Attending Delivery

Highlights in the history of a very old profession, with references for more information elsewhere.

“Well-behaved women rarely make history.” (Laurel Thatcher Ulrich)

I. Long Ago and Far Away

Midwives have been part of the human experience for as long as we know.”The ancient Jews called her the wise woman, just as she is known in France as the sage-femme, and in Germany, the weise frau and also Hebamme or mother’s adviser, helper, or friend. The English ‘midwife’ is derived from Middle English “mit wif, or with-woman”(J.H. Aveling). The Latin term cum-mater and the Spanish and Portuguese term comadre, have the same meaning: with woman.

The midwife is mentioned in the Book of Genesis, 35:17: “And when she (Rachel) was in her hard labor, the midwife said to her, ‘Fear not, for now you will have another son.’” The book of Exodus, 1:20 states, “Therefore God dealt well with the midwives: and the people multiplied, and waxed very mighty.”

In ancient times and in primitive societies, the work of the midwife had both a technical or manual aspect and a magical or mystical aspect. Hence, the midwife was sometimes revered, sometimes feared, sometimes acknowledged as a leader of the society, sometimes tortured and killed. The midwife had knowledge and skill in an area of life that was a mystery to most people. Since women had no access to formal education, it was widely assumed that the midwife’s power must come from supernatural sources, such as an alliance with the devil. During the Middle Ages, a frenzy of witch-burning, promoted by both church and civic authorities, was responsible for the killing of up to several million women, many of whom were midwives and healers. In her book on Woman as Healer, Jeanne Achterberg describes the witch-hunts as “an evil that surpasses rational understanding. Here was, indeed, the worst aberration of humanity, and it trickled down the hierarchy of authority.”

Today, in much of the world, professional midwives are responsible for attending women in labor and birth. In fact, in the countries with the best pregnancy outcomes, midwives are the primary providers of care to pregnant women. However, midwives are still prosecuted and persecuted for following their vocation, although not in the extreme way that characterized the Middle Ages.

II. The Beginnings of Midwifery in America

In the U.S., midwives, like physicians, practiced without specific education, standards, or regulations until the early part of the 20th century. Although detailed statistics were lacking, the evidence available showed that midwives’ patients were less likely than physicians’ patients to die of childbed fever or puerperal infection, the most significant cause of maternal morbidity and mortality at the time.  This discrepancy was probably in large part because, in an era where Semmelweis’s germ theory was little known and largely dismissed by physicians, who moved from the delivery room to the anatomy lab and the medical wards, then back to the delivery room, without washing their hands.

One American midwife and healer named Martha Ballard, who practiced in Maine between 1785 and 1812, kept a diary of her life and work. On the basis of this diary, Laurel Thatcher Ulrich wrote a portrait of Martha Ballard’s life and work, A Midwife’s Tale, published in 1990. Ulrich’s book won a Pulitzer Prize and was made into a film. To explore more about Martha Ballard, visit www.dohistory.org, or read Ulrich’s fascinating account by clicking on the title to order.  To find other books about traditional midwives in America, go to the “homage to our foremothers page” on Marilyn Greene‘s midwifery site.

In the half-century between 1770 and 1820, upper-class women in American cities started to favor “male midwives,” or physicians. According to Catherine Scholten in her book, “Childbearing in American Society: 1650-1850,” “the presence of male physicians in the lying-in room signaled a general change in attitudes toward childbirth. With changing conditions of urban life, new perceptions of women, and advancements in medical science, birth became increasingly viewed as a medical problem to be managed by physicians. At the same time, because medical training was restricted to men, women lost their positions as assistants at childbirth, and an event traditionally managed by a community of women became an experience shared primarily by a woman and her doctor.” However, since the interest of the male midwife was an economic one, it did not extend to lower-class women, black women, or immigrants. During the nineteenth century, midwives continued to care for these women.

As medicine gained legitimacy and power toward the end of the nineteenth century, it called for the abolition of midwifery and home birth in favor of obstetrics in a hospital setting, a goal that it almost accomplished. In 1900, midwives attended almost half of all births; by 1935, the number had decreased to 12.5%. Midwives were portrayed as dirty, illiterate, and ignorant, and women were convinced that they were safer in the hands of doctors and hospitals. After providing care to women during the formative decades of our country, midwives were effectively stamped out in the early years of the 20th century.

III. The Medicalization of Childbirth

Physicians trained in the specialty of obstetrics and gynecology declared themselves to be the proper caregivers for childbearing women, and the hospital was deemed to be the proper setting for that care. Birth evolved from a physiological event into a medical procedure. According to one of the foremost authorities of the day, Dr. Joseph DeLee, birth was a dangerous process from which few women escaped unscathed, and proper management of this pathological condition required a program of routine medical intervention. DeLee’s recommended interventions included anesthesia, episiotomy, and assisted (forceps) delivery.

By the 1960s, these interventions were common in all American hospitals and women were unaware of any other way to give birth (as well as unaware when they were giving birth!). In addition, women were forced to labor without presence or support from partners or family, infants were taken from the mother at delivery and cared for in newborn nurseries, bottle feeding of formula became the norm, and babies born outside the sterile environment of the operating room were labeled contaminated and kept separately. There was no scientific rationale for any of these procedures; to the contrary, many of them were eventually shown to be harmful.

Midwifery, meanwhile, was declared to be illegal in most jurisdictions, and as the old “granny” midwives died out, the profession almost died with them. Midwifery never succumbed completely to the campaign waged against its practitioners by the medical profession. Granny midwives in the rural south continued to serve poor, mostly black women. Motherwit is the story of one such midwife, Onne Lee Logan, who was born in 1910 in Sweet Water, Alabama, the fourteenth of sixteen children and the daughter of a midwife. She learned her midwifery by accompanying her mother to births. Eventually she became the most widely respected and sought after midwife in the region; in the book, she share her stories, secrets, faith, and wisdom. Listen to Me Good: The Life Story of an Alabama Midwife is the story of another Alabama midwife, Margaret Charles Smith.

IV. Modern Nurse-Midwifery

During its darkest times, the seeds of the future of midwifery were being sowed. Although slow to grow, they proved to be enduring. On one front, public health nurses with the Frontier Nursing Service in the mountains of Kentucky and the Maternity Center Association in the medically underserved neighborhoods of New York City in the 1920s acquired additional training in midwifery to provide maternity services to women who were being ignored by the physicians and receiving inadequate maternity care. They called themselves nurse-midwives. (To learn more about the history of the Frontier Nursing Service, read Wide Neighborhoods, the autobiography of its founder, Mary Breckenridge. Mary Breckenridge introduced modern nurse-midwifery, based on the British model, into the United States. In 1925 she established the FNS as a demonstration project of complete family health care in a remote rural area, and directed it until her death in 1965.) By the 1950s, nurse-midwives were well established in several medical institutions, and nurse-midwifery education was moving into institutions of higher learning and becoming standardized. In 1955, a small group of nurse-midwives founded the American College of Nurse-Midwifery, which merged with the American Association of Nurse-Midwives in 1968 to become the American College of Nurse-Midwives (ACNM). The ACNM developed standards for nurse-midwifery practice, core competencies for midwifery education, and certification for nurse-midwives.  More recently, the ACNM has included a path to certification for midwives without a nursing background, certified as CMs or certified midwives.  

Although home birth had been the norm in the early days, nurse-midwives gradually moved almost completely into hospital settings, usually relinquishing control and autonomy over their practice to physicians and adopting some of the interventive procedures used by them. The trade-offs for these losses included a legal sanction to practice, assurance of appropriate physician consultation when needed, and a living wage. More recently, most nurse-midwives have been able to obtain prescriptive privileges, hospital-admitting privileges, and the right to third-party reimbursement (insurance payment).  Nurse-midwifery is legal and regulated by licensure in all 50 states.

Nurse-midwifery practice grew rapidly from the 1980s into the new millenium; “according to the American Midwifery Certification Board, there are 13,071 CNMs and 84 CMs” in practice in the US.  The vast majority of midwives in the United States are CNMs. with nurse-midwives assuming a large part of the care of under-served and vulnerable women from isolated rural and impoverished inner-city areas. Many of these women bring with them significant psychosocial problems that put them at an increased risk for poor obstetric outcomes. Nonetheless, data showed from the beginning, and continue to show, that these women experience superior outcomes with nurse-midwifery care.

Also in the 1970s and 80s, interest grew in out-of-hospital birth centers where nurse-midwives could practice without the distractions (and dangers) of the hospital.  In response to consumer desire for alternative care, Maternity Center Association (MCA) in New York opened the Childbearing Center in in brownstone house on the Upper East Side in 1975.  By 1979, there were at least 14 birth centers across the country, a tour of the centers found that they were all experiencing the problems of being change agents and needing assistance. The Maternity Center Association obtained funding “to found the Cooperative Birth Center Network (CBCN) and to fund the first national (retrospective) study of outcomes of care in 14 centers  (Bennetts AB and Lubic R)Anita B. Bennetts and Ruth W. Lubic, “The Free-Standing Birth Center.”   In 1983, the American Public Health Association (APHA) published “Guidelines for Regulating and Licensing Birth Centers.” (American Journal of Public Health, Vol. 73, No. 3, March 1983). The same year, CBCN became the American Association of Birth Centers (formerly the National Association of Childbearing Centers) “with a multi-disciplinary professional and consumer Board of Directors.”

V. The Rebirth of Home Birth

On a second front, in the late 1950s, consumers of hospital-based, medicalized maternity care began to rebel. There was a growing interest in childbirth education, breastfeeding, and natural childbirth. Women and families who were pessimistic about their chances of having a safe and satisfying birth in the hospital began to explore the option of home births with midwives.

The midwives who attended these births were unlikely to be professionally educated as midwives; their interest in midwifery was frequently though personal birth experiences; their training was by apprenticeship, and their practice was by and large unregulated, either illegal or not mentioned in the law. Initially, they were not organized, but worked in isolation in diverse parts of the country.

Gradually, the phenomenon attracted the attention of state regulatory authorities and the medical profession, who began to clamp down on “lay” midwives, in some cases arresting or prosecuting them for practicing medicine without a license. Despite restrictions, a small but steady number of families continued to demand alternative childbirth, and the midwives attending them began to organize to share experiences, support one another, and learn together. During the 1970s, the proportion of out-of-hospital births almost doubled, although the overall number was small. In 1975, the publication of Ina May Gaskin’s book, “Spiritual Midwifery,” spread the word that childbirth could be an experience of growth, empowerment, and joy. For an interesting recent online article on Ina May, see http://www.salon.com/people/bc/1999/06/01/gaskin/.

In 1982, the Midwives’ Alliance of North America (MANA) was founded. The organization embraces all midwives, regardless of training or credentials; however, its focus became the expansion of practice rights for direct-entry midwives who attended home births. The midwives represented by MANA have steadfastly insisted on autonomy and control over their practice, and differentiation of the midwifery model of care from the medical model. This freedom to practice without outside control has not been without costs; the midwives have had to confront lack of legal standing, hostile practice environments, lack of appropriate medical consultation and referral mechanisms, and low pay for long hours of work.

VI. Current Trends and the Future of Midwifery

During the 1990s, differences between the two groups of midwives became less distinct, although they remain. Through MANA, direct-entry midwives developed standards for accreditation of educational pathways (MEAC, the Midwifery Education Accreditation Council)  and for certification of midwives (NARM, the North American Registry of Midwives); they formed separate organizations to perform these functions.They worked for legalization of midwifery practice at the federal and state level, and for improved interaction with the health-care system.

Meanwhile, ACNM began to accredit direct-entry midwifery educational programs and to work for increased autonomy of nurse-midwives through legislative and regulatory changes.  CNMs and CMs are gaining increasing autonomy with prescription privileges, better reimbursement from insurance, independent hospital privlleges, although the rules and regulations vary widely in different states.

Most importantly, scientific validation for the midwifery model of care began to emerge in the literature, much of it contained in a massive review of 7000 clinical research studies known as “Effective Care in Pregnancy and Childbirth,” or familiarly as the Cochrane database. This systematic review of the scientific evidence classified the elements of care during pregnancy and childbirth as effective, promising, not proven either way, or not worth using. Many of the elements of the midwifery model of care were validated by this ongoing review, which became the midwives’ bible.  The summary of the most recent Cochrane review of midwifery care is worth reading here in its entirety:

“In this review we included models of care where midwives provided care throughout the pregnancy, and during labour and after birth. We identified 13 studies involving 16,242 women both at low and increased risk of complications. Midwife-led continuity of care was associated with several benefits for mothers and babies, and had no identified adverse effects compared with models of medical-led care and shared care. The main benefits were a reduction in the use of epidurals, with fewer episiotomies or instrumental births. Women’s chances of being cared for in labour by a midwife she had got to know, and having a spontaneous vaginal birth were also increased. There was no difference in the number of caesarean births. Women who received midwife-led continuity of care were less likely to experience preterm birth, or lose their baby before 24 weeks’ gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. All trials included licensed midwives, and none included lay or traditional midwives. No trial included models of care that offered out of hospital birth. – See more at: http://summaries.cochrane.org/CD004667/midwife-led-continuity-models-versus-other-models-of-care-for-childbearing-women#sthash.9w2DMgzQ.dpuf”

At the present time, there is no doubt that midwives who meet the standards and qualifications of the International Confederation of Midwives offer women safe, effective care with good outcomes; now midwives ourselves are looking at our practice to see just what we do that makes this so. We believe that the answer lies in our name; that is, we are “with women.” We listen to women, we talk with women, we stay with women.

Every year, more American babies are born into the hands of midwives. The national average for CNMs/CMs is 7.8% of all births or 11.7% of vaginal births , although in some states it is as high as 20%. This accounts for about 92% of all midwifery births.  Still, the rate is very low compared to that in the European countries with the best birth outcomes. Midwives believe that our care can enhance the experience of pregnancy and birth for women. Hopefully, this website will inform women about midwives and encourage midwives to come together and to learn from one another.

References and Sources of Additional Information on the History of Midwives

Achterberg, Jeanne. Woman as Healer. Boston: Shambhala Publications, 1990.

American Public Health Association, Guidelines for Regulating and Licensing Birth Centers. American Journal of Public Health, Vol. 73, No. 3, March 1983.

Bennetts AB and Lubic RW. “The Free-Standing Birth Center.” The Lancet, 2/13/82).

Breckenridge, Mary. Wide Neighborhoods: A Story of the Frontier Nursing Service. Lexington: The University Press of Kentucky, 1981.

Kitzinger, Sheila, ed. The Midwife Challenge. London, Pandora Press, 1988.

Logan, Onnie Lee as told to Katherine Clark. Motherwit: An Alabama Midwife’s Story. New York: E.P. Dutton, 1989.

Rooks, Judith P. Midwifery & Childbirth in America. Philadelphia: Temple University Press, 1999.

Sandall J, Soltani H, Gates S, Shennan A, Devane D.  Midwife-led continuity models versus other models of care for childbearing women.  Cochrane Summaries.  Publish online August 21, 2013.  – See more at: http://summaries.cochrane.org/CD004667/midwife-led-continuity-models-versus-other-models-of-care-for-childbearing-women#sthash.IjsJEwQh.dpuf

Scholten, Catherine M. Childbearing in American Society: 1650-1850. New York: New York University Press, 1985.

Ulrich, Laurel Thatcher. A Midwife’s Tale: the Life of Martha Barrard, Based on Her Diary, 1785-1812. New York: Random House, 1990.