A Short History of Midwifery

Highlights in the history of a very old profession, with references for

more information elsewhere.

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

If you don't have time to read the whole story of midwifery as presented here, click on the
part that interests you the most:

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 midwife, 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.{mospagebreak}

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.

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.{mospagebreak}

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,
bottlefeeding 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.{mospagebreak}

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).

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 practice grew rapidly in the 1980s and 1990s, with nurse-midwives
assuming a large part of the care of underserved 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.{mospagebreak}
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.
{mospagebreak}

VI. Current Trends and the Future of Midwifery

During the 1990s, differences between the two groups of midwives became less distinct.
Through MANA, direct-entry midwives developed standards for accreditation of educational
pathways and for certification 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.

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.
At the present time, there is no doubt that 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 is 7.4%, although in some states it is as high as 20%. 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