THE HISTORY OF MIDWIFERY IN THE UNITED STATES

Physicians in Colonial times were largely uneducated.  In 1765 the first medical school was chartered, but the number of medical schools did not begin to multiply until after the War of 1812 [2].  Also in 1765, Dr. William Shippen opened the first midwifery school. However, many women at that time were illiterate and could not afford formal education, so Shippen’s lectures were soon limited to male students [2,5].  Following the War of 1812, the nascent medical schools were largely for-profit institutions that began churning out poorly prepared graduates [6].  There were few opportunities available for higher education to women of that period.  Women were considered less intelligent and less capable of learning than men, and societal beliefs stated that once a woman married, she should bother simply with domestic matters [2,6].  Furthermore, attempts to start midwifery schools were denied federal funding [2].  As a result, midwives were unable to keep up even with the inadequate education available to physicians, and they instead were required to continue relying on wisdom passed down through apprenticeships and learning from their own experiences, with only herbs and home remedies as the resources available to them [3].  The misguided belief that men were more equipped to safely deliver a woman through labor and delivery began to proliferate [1].

However, this misguided belief was not the only motivating factor causing women to discard centuries of tradition with midwives.  The other very powerful driving force was the advent of anesthetics in the mid 1800s for use during labor and childbirth.  Toward the end of the 1800s, there were great advances in the field of medicine as well as in the availability of anesthetics during labor and delivery [2,7].  As anesthetics were only available in a hospital setting under a physician’s care, more woman began to desire hospital births.  Hence, as hospitals began to proliferate, midwifery care became reserved for only those women who were unable to pay for a physician.  However, midwives continued to attend the majority of births in the U.S. until the early 20th century [8].  At that time, physicians were commanding more and more control over all medical fields, and wanted to eliminate all competition [1,9,3].  As a result, the number of midwife attended births began to quickly decline.

In addition to lack of educational opportunities and lack of access to medical advances, the absence of organization within the midwifery community, as well as racial and gender bias, was devastating to the midwifery profession [1].  This was in stark contrast with the growing organization and power of the medical community.  The medical community began to target the midwife as they realized that there was money to be made in caring for the pregnant woman [1].  “As the presence of medicine became highly competitive, physicians and medical students were advised that their presence at a delivery would insure the entire family as grateful patients thereafter” [3].  As a symbol of the power they were amassing, the American Medical Association was formed in 1848 to “enforce standards on medicine as well as its practice” [2].  With their new organization and rising power, the medical community began their full onslaught of midwifery, dubbing it “the midwifery problem,” and painted midwives as “slovenly, immoral, drunken, promiscuous, and perverse” [1].

The medical community itself began to come under fire in the early 1900s, however.  The Carnegie Foundation was awarded an endowment that was to be used “for the benefit of teachers in the colleges and universities of the United States, Canada, and Newfoundland,” [10].  The Carnegie Foundation appointed a board of trustees who performed a brief review of colleges and universities and discovered that, “there was little unity of purpose or of standards,” [10] among the schools.  Before they bestowed the endowment on any schools, the board felt it was necessary for an impartial party to inspect the current colleges and universities to ensure they offered quality education.  They hired Abraham Flexner, a former headmaster of a private Kentucky high school, who visited each of the 155 medical schools in North America.  Using Johns Hopkins University as his exemplar, Flexner scrutinized the quality of the education that each school offered[6].  The result of his effort is now known as the Flexner Report.  In his report to the Carnegie Foundation, Flexner stated that there was “an enormous over-production of uneducated and ill trained medical practitioners,” which he went on to say was “in absolute disregard of the public welfare and without any serious thought of the interests of the public” [10].  He felt the schools were more about profit than education.  The Flexner Report spurred a transformation of medical education in North America.  Within a decade medical education become more demanding and scientifically founded, and approximately one-third of the medical schools had closed or merged with other schools [6].  Unfortunately, most of the remaining medical schools still did not offer education to women [6].  As a result of the unremitting lack of opportunity, midwifery education was unable to keep up with the improvements in medical education.

The continued suppression of the midwife by the now very powerful medical community began to really take its toll.  In the year 1900, physicians attended roughly half of all births, but less than 5% occurred in the hospital.  By the early 1920s up to 50% of births occurred in hospitals [2].  Birth was no longer considered natural, but was now viewed as a medical event in need of management by a physician.

“[In 1920] Dr. Joseph DeLee, author of the most frequently used obstetric textbook of the time, argued that childbirth is a pathologic process from which few escape “damage.” He proposed a program of active control over labor and delivery, attempting to prevent problems through a routine of interventions. DeLee proposed a sequence of medical interventions designed to save women from the “evils” that are “natural to labor.” Specialist obstetricians should sedate women at the onset of labor, allow the cervix to dilate, give ether during the second stage of labor, cut an episiotomy, deliver the baby with forceps, extract the placenta, give medications for the uterus to contract and repair the episiotomy. His article was published in the first issue of the American Journal of Obstetrics and Gynecology. All of the interventions that DeLee prescribed did become routine.” [2]

By 1935, physicians were attending the gross majority of births. While physician care and hospital birth became the norm, the number of perinatal deaths increased by 40-50% between 1915 and 1930 [2].  By 1945 midwife attended births had dropped to 5%, and by 1975 less than 1% of births in the U.S. were attended by midwives[8].  As the government tried to eradicate midwifery, midwives, who were often illegal and practicing underground, continued to serve lower class women who were unable to afford medical care and would have otherwise gone without care[9].  Oftentimes these midwives were untrained immigrants or the so-called Granny midwives of the deep south who were descended from slaves, and their lack of knowledge about hygiene and modern medical discoveries added fuel to the fire that midwives were uneducated and dangerous as care providers [9].  Additionally, during and following World War I, immigration into the United States was limited.  This not only limited the number of experienced midwives coming into the country, but also limited the primary source of people seeking midwifery care [2].

The tide began to slowly change in the late 1960s when a grassroots movement, spurred by increasing numbers of surgical births and interventions, had begun to move back toward natural birth and away from the over medicalization and lack of choice that was all too common in the hospital [2,9].  Birth in the hospital also began to change somewhat during this time as women wanted more from their birthing experience.  Fathers began to be allowed in the delivery room, and women were left conscious during the delivery.  However, a rise in lawsuits continued to influence doctors and encouraged them to continue managing the birth as a medical event, a continued driving force in the hospital to this day [9].

In the 1970s, the American College of Nurse-Midwives, which was formed in 1955, devised national standards for the education and certification of the Certified Nurse Midwife (CNM), much like the transformation exacted following the Flexner report.  In 1971 ACNM issued a statement against out-of-hospital birth, which they rescinded in 1980 [2].  CNMs began to gain numbers, growing to approximately 1000 CNMs nationwide by the end of the decade [8].  CNMs are now recognized as primary healthcare providers by federal law and are licensed with prescriptive authority in all 50 states [11].

The reprofessionalization of the direct-entry midwife (DEM) did not begin until 1982 with the founding of the Midwives Alliance of North America (MANA) [12].  MANA established a board to develop a written exam based on the MANA Core Competencies.  This board evolved into the North American Registry of Midwives (NARM), and the exam was the beginning of the CPM credential [8].  In 1994 the first CPM credential was awarded, and by 2014 over 2454 CPM certifications had been issued [13].  Currently, the number of women choosing homebirth is also increasing [14,15].  To date, direct-entry midwifery continues to be unregulated in 21 states and is illegal in 10 of the 21 unregulated states [18].  After hitting a low of approximately 1% In 1980, the number of babies being caught by midwives in the U.S. is now increasing [2,14].

Even though, CPMs are still far from being endorsed by the medical community, attitudes about birth choices and care providers are beginning to change.  In recent months the American College of Obstetricians and Gynecologists (ACOG) began to loosen its stance against CPMs and out-of-hospital births.  In February of 2015, ACOG released a statement acknowledging that birth centers attended by CPMs were viable options for low-risk women [16].  ACOG’s latest statement concerning CPMs and homebirth was issued in August of 2016.  The Committee on Obstetric Practice [17] issued a report that acknowledges that women have the right to choose the location of their birth, but advises that women make informed decisions about their choice of care provider and states that “appropriate” care providers are physicians practicing obstetrics, CNMs, Certified Midwives (CMs), or midwives “whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education”.

Midwifery has had a long, hard road in the U.S.  With the continued acceptance of the mainstream medical community, and the continued demand of the consumer for care following the Midwives Model of Care™, we are hopefully on a road that will end with more babies being born into the hands of midwives.

1. Davis, E. (2004). Heart & hands (4th ed.). Berkeley: Celestial Arts.
2. Feldhusen, A. E. (2000). The history of midwifery and childbirth in America: A time line. Midwifery Today. Retrieved from http://www.midwiferytoday.com/articles/timeline.asp
3. Varney, H., Kriebs, J. M., & Gegor, C. L. (2004). Varney’s midwifery (4th ed.). Sudbury: Jones and Bartlett Publishers.
4. Wertz, R. W., & Wertz, D. C. (1977). Lying-In: A history of childbirth in America (Expanded ed.). New Haven: Yale University Press.
5. Leavitt, J. W. (1986). Brought to bed: Childbearing in America, 1750-1950. New York: Oxford University Press.
6. Irby, D. M., Cooke, M., & O’Brien, B. C. (2010). Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine, 85(2), 220-227. doi:10.1097/ACM.0b013e3181c88449
7. Frye, A. (2008). Holistic midwifery: A comprehensive textbook for midwives in homebirth practice (Vol. I: Care during pregnancy). Portland: Labrys Press.
8. National Association of Certified Professional Midwives [NACPM]. (2014a). History of Certified Professional Midwifery and NACPM. Retrieved from http://nacpm.org/about-nacpm/history/
9. Martin, K. (n.d.). Short history of midwifery. Retrieved from Gentle Delivery Childbirth Services: https://gentlemidwife.wordpress.com/a-short-history-of-midwifery/
10. Flexner, A. (1910). Medical education in the United States and Canada. New York City: Carnegie Foundation for the Advancement of Teaching. Retrieved from http://archive.carnegiefoundation.org/pdfs/elibrary/Carnegie_Flexner_Report.pdf
11. American College of Nurse-Midwives [ACNM]. (2016, February). Essential facts about midwives. Retrieved from http://www.midwife.org/Essential-Facts-about-Midwives
12. Midwives Alliance North America [MANA]. (n.d.). What is a midwife? Retrieved July 30, 2016, from http://mana.org/about-midwives/what-is-a-midwife
13. National Association of Certified Professional Midwives [NACPM]. (2014b). Who are CPMs. Retrieved August 1, 2016, from http://nacpm.org/about-cpms/who-are-cpms/
14. Cheyney, M., Everson, C., & Burcher, P. (2014). Homebirth transfers in the United States: Narratives of risk, fear, and mutual accommodation. Qualitative Health Research, 24(4), pp. 443-456. doi:10.1177/1049732314524028
15. MacDorman, M. F., & Declercq, E. (2016). Trends and characteristics of United States out-of-hospital births 2004-2015: New information on risk status and access to care. Birth, 43(2), 116-124. doi:10.1111/birt.12228
16. The American College of Obstericians and Gynecologists [ACOG], & Society for Maternal-Fetal Medicine [SMFM]. (2015). Obstetric care concensus. Retrieved from http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Levels-of-Maternal-Care
17. Committee on Obstetric Practice. (2016). Committee opinion No. 669. The American College of Obstetricians and Gynecologists [ACOG]. Retrieved from https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co669.pdf?dmc=1&ts=20160725T1919187348
18. North American Registry of Midwives [NARM]. (2016). Advocacy. Retrieved from http:// narm.org /advocacy