Women have helped women deliver babies since the inception of human kind. Across the centuries, this role has been a treasured one. Even in the face of childbirth’s many challenges and perceptions, midwives have provided emotional, physical, and mental support to women giving birth.
In the beginning, “midwifery” was not considered a formal profession. Women simply supported other women as they gave birth to their children. Over time, however, the word “midwife”, meaning “with-woman”, became the perfect description of the devoted women who stood by mothers’ sides. The midwife was a mainstay in the birthing process.
From the 1600s to the 1900s, midwives practiced with relative freedom. Laws regulating midwifery in the U.S. were lenient, and most were mandated locally. The limits imposed on midwives varied widely across the country, but in general, midwives provided primary support to women during pregnancy, birth, and postpartum.
Until the late 1800s, people viewed midwifery as a necessary, life-giving practice. Over time, however, and especially in the 1900s, midwifery became increasingly scrutinized, regulated, and even outlawed.
While it is impossible to clearly illustrate the evolution of midwifery in this short article, we can at least offer some of the critical moments and influences that shaped midwife history.
The “Midwife Problem”
Until the 1900s, midwives attended the majority of births in the U.S. They practiced with limited government intervention, and evidence showed that midwives often had better outcomes than physicians[i].
Despite midwives’ success, public opinion of midwifery began to transform in the early 1900s. Much of the transition was stimulated by social, economic, and political factors, and the U.S. soon gave birth to the “midwife problem.”
According to the National Association of Professional Midwives, “the ‘midwife problem’ was a focus of debate among physicians, public health advocates and social reformers who were concerned about infant mortality and the well-being of childbearing women.” Those debates were often fueled by racism, sexual discrimination, and anti-immigrant fervor[i]. Concurrent to those debates, “social change, increasing prosperity and technologic developments…led some women to seek care in hospitals where physicians could administer anesthesia[i].” By the first part of the 19th century, midwives attended only about half of all births in the U.S., and physicians attended the others[ii].
From many perspectives, the events and culture of the late 1800s and early 1900s shifted midwifery practice for better and worse.
A Change in the Cultural Discourse: Regulating and Reducing Midwifery
In the first decades of the 20th century, a pathology-oriented medical model of childbirth supplanted the traditional role of midwives in the United States[ii]. Public education campaigns lauded the benefits of this model, and women increasingly gave birth in hospitals under the supervision of doctors. By 1935, fewer than 20% of women were attended by midwives. By the end of WWII, only 5% of women used midwife services[iii].
Contributing to the decline in midwifery was the expansion of scientific knowledge in the field of medicine. Scientific inquiry revealed advances in medicine and technology that doctors applied to obstetrics practice. Because midwives primarily practiced informally, much of the new knowledge in medicine was not disseminated within the midwifery profession[iv]. Additionally, social, political, and economic issues and agendas continued to promote an emerging discourse that giving birth was a “destructive pathology”, and one that required medical, hospitalized care.
In 1915, Dr. Joseph DeLee, the father of obstetrics and a well-respected author of the time, helped establish this growing narrative. He described birth as damaging to both mothers and babies and proposed a sequence of interventions that would save women from the “evils natural to labor.” These interventions included the routine use of forceps, sedatives, and other medications[ii]. Eventually, the “homeopathic remedies and traditions practiced by generations of midwives began to appear in stark contrast to more ‘modern’ remedies suggested by physicians[iv].”
At the same time, scientific evidence increasingly suggested that midwife-attended births had “poorer statistical outcomes that physician attended deliveries[iv].” Politicians, doctors, and others used this data to pass legislation to increasingly restrict midwife practice. Overtime, it became illegal to practice midwifery in many states.
However, much of the data collected in the early 20th century did not account for other factors that contributed to poor neonatal outcomes for midwife-attended births. As wealthier women pursued obstetric care, poorer women and women living in rural areas continued to use midwife care. Poor nutrition and sanitation were the norm in impoverished urban centers and rural areas, and less privileged women and women living rurally faced many environmental issues, all of which could contribute to poor neonatal health[iv].
Throughout the early to mid-1900s, midwifery continued to decline in the United States. Medical and scientific advances, anti-immigration laws, segregation, patriarchy, and poverty were all contributing factors. For example:
“Immigration was limited during and after World War I and thus reduced the supply both of foreign-trained midwives and the number of foreign-born women, the most loyal clientele of midwives[v].”
Physicians became wealthier and were integrated into middle- and upper-class societies. This helped increase their popularity and perceived credibility[v].
“Prejudice against the intelligence and capability of women, immigrants, black people and poor people was used to defame midwifery[v].”
“Midwives were not in a position of power; they made relatively little money, were not recognized and did not see themselves as professionals[v].”
Each of these factors and others contributed to the decline of defamation of midwife practice in the U.S. In addition, there were many events that and circumstances that shaped midwifery history:
In the last half of the 1800s, medicine became professionalized in the spirit of competition[ii]. Politicians and other professionals devoted financial and political resources to promoting this competition, and midwifery suffered the consequences.
In the late 1800s, the development of public hygiene and news discoveries in bacteriology helped doctors lower the infant mortality rate. This made hospital- and doctor-provided care appealing options for women who could afford it.
In 1910 and 1912, two reports on medical education concluded that obstetricians in the U.S. were poorly trained; one report recommended hospitalization for all deliveries and the gradual abolition of midwifery. It also recommended that poor women attend charity hospitals that could serve as training sites for obstetricians[ii].
Over the next several decades, public policy and social, economic, and political culture continued to influence midwives’ roles, scope of practice, and legality in the U.S.
The Professionalization of Midwives in the U.S.
Throughout the 1900s, advocates of midwifery fought for midwives’ rights and the discipline itself across the U.S.
In the 1920s, nurse midwifery originated and eventually became a widely recognized profession in the 1970’s when the American College of Nurse-Midwives (ACNM) established national standards for education and certification. This stimulated federal funding for the field, and trained, educated nurse-midwives began to gain legal standing and respect in the medical community[iii].
In the 1970s, more and more women demanded their rights to normal, natural birth outside of the hospital, and the demand for midwifery began to increase. By 1982, a group of dedicated midwives founded the Midwives Alliance of North America (MANA). MANA sought to professionalize the field of midwifery and make midwifery legally available to more women.
According to the National Association of Certified Professional Midwives, “MANA’s role was central to the development and evolving philosophy of contemporary direct-entry midwifery[iii].” MANA worked diligently to establish legally-recognized and well-respected standards for professional certification and eventually won the respect of many state governments. MANA also used its Midwifery Task Force to establish a women-centered, “Midwives Model of Care™”. This model provides a professional and established standard to direct midwives and command respect and recognition for the field. MANA helped professionalize the field of midwifery and make it what it is today.
Since then, advocates for midwifery have continued to work together to establish professional standards in the field. They’ve increased women’s knowledge of midwife services, and they’ve worked with policy-makers, medical professionals, and other influential agencies to establish high-quality education, training, and certification, recognized by state governments and the federal government.
Their hard work saw the creation of numerous agencies that continue to fight for midwives rights and expansion in the field. Organizations such as the North American Registry of Midwives, the Midwifery Education Accreditation Council, the American Midwifery Certification Board, the American College of Nurse-Midwives, and the Midwives Alliance of North America continue to expand midwife training, legality, and practice in the U.S. today.
Despite the relatively recent professionalization of midwifery, advocates still fight for midwife equality. According to MANA, while nurse-midwives can practice legally in all 50 states, certified professional midwives are legally authorized to practice in just 28 states, and certified midwifes can only practice legally in 3 states[vi].
When women or men pursue careers in midwifery, they help establish the field as a respected and recognized entity. As this happens, more colleges and universities respond with increasingly high-quality programs that train nurse-midwives and others for success in the field. As more and more midwives pursue education in the field, the many agencies working to professional midwifery respond with increasing resources and advocacy for midwives. Eventually, this cycle can result in the expansion and improvement of a field as old as time.