History of Midwifery
From the earliest cave drawings we know that women were the herb gatherers who attended women in childbirth and cared for the sick in their clan. Hieroglyphics tell us the same of ancient Egyptian culture. The Bible states 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." The midwife has knowledge and skill in an area of life that is a mystery to most people and she has been seen as magical and as a healer in many cultures. An incredible story about midwifery in biblical times is The Red Tent by Anita Diamant.
The derivation of the word midwife is from the Anglo-Saxon "mit wif" or with woman. The ancient Jews called her the wise woman - as she is known in France (sage-femme) and Germany (weise frau).
In the Middle Ages, women from one village to the next continued to tend the sick and care for women during labor and birth. Eventually, the ruling class and the Medieval Church sanctioned the new male medical profession of physicians, many of whom were priests, had little to no training, and exalted the persecution of lay healers and midwives. Many women were tortured and burned or hung as heretics or witches in an effort to suppress the competition. The transmission of knowledge from Grandmother to Mother to Daughter was interrupted during the burnings when children were coerced by authorities to report their family members as witches if they performed any healing practices.
Medicine became scientific and profitable and therefore was the province of professional males who were trained through educational institutions which, correspondingly, was not made available to women.By the 1600s and 1700s midwives in Western Europe consisted of "urban" and "traditional" midwives. The urban midwives were formally trained and supervised by professional bodies as opposed to traditional midwives who practiced in small rural towns and villages without formal training or supervision.
In early America, midwives, like physicians, practiced without specific education, standards or regulations until the early 1900s. The evidence available shows that midwives patients were less likely than physicians' patients to die of childbed fever or puerperal infection, which were the most significant causes of maternal morbidity and mortality at the time.
Before 1750, births with male attendants were most frequently associated with emergencies. Then a smear campaign began against midwives by male medical professionals which eroded the public confidence in midwives. Medical doctors gradually extended their control by managing a woman's entire pregnancy in general rather than just in cases of difficulty or emergency. At this time the forceps and speculum were introduced into practice. These instruments enabled doctors to severely alter the dynamics of the previously female domain of childbirth. The speculum enabled male doctors to circumvent the prohibition of touching female genital organs by men. In a more profound way the forceps represented intervention and manipulation of birth. These instruments greatly marginalized the midwife.
Also assisting this change was a pervasive social trend. Toward the end of the 1800s emerged the lying-in hospital. Advertised as safe and sterile, clean and civilized, this became the preferred environment for persons needing care. Along with the smear campaign against midwives, this shifted the public preference from the birth place at home to the hospital, and so began the monopoly of the medical establishment over birth. Also, upper class women began to favor male medical doctors. This was a status symbol for the aristocracy while lower class and rural women continued to be served by midwives.
For a detailed history of this moment in time, read A Midwife's Tale:The Life of Martha Ballard, Based on Her Diary, 1785-1812 by Laurel Thatcher Ulrich.
Along with the public trend was the problem that medical training was restricted to men only, so women lost their positions as assistants at birth and an event traditionally attended by a community of women became an experience shared primarily by a woman and her doctor. Another excellent read about this historical phenomenon is Childbearing in American Society: 1650 – 1850 by Catherine Sholten. However, since the interest in the male medical doctor was an economic one, it did not extend to lower class women, black women or immigrants. Therefore, all through the 19th century midwives continued to care for these women.
As the medical establishment gained legitimacy and power toward the end of the 19th century, it called for the abolition of midwifery and home birth. This would solidify obstetrics and the hospital setting as the dominant ruler of childbirth and maternity care. This hostile takeover was almost accomplished. In 1900 midwives attended half of births; by 1935 the number had decreased to 12.5%. The active and deliberate marketing campaign against midwives had flourished by this time. Posters were hung all over the public with wart-faced, hook-nosed, evil-witch-looking women with dirty hands and ragged clothing with a medical definition of a midwife: dirty, illiterate and ignorant. Women became convinced by these and other tactics that they were safer in the hands of doctors and hospitals. After ages of providing care to women, midwives were stamped out in America in less than half a century. Meanwhile, in countries where midwives continue (to this day) to attend the majority of births, better outcomes are reported as well as lower maternal and infant morbidity and mortality.
In order to maintain its grip on maternity care, medicine declared pregnancy and childbirth pathological conditions rather than natural events. This view is still widely held by the public today. It is an unconscious belief carried over from one generation to the next and has its roots in the active and deliberate smear campaign against midwives, not evidence or statistics. By convincing the public of this inaccurate view and instilling people with fear, midwifery was/is able to be completely dominated. Physicians trained in the specialties of obstetrics and gynecology declare themselves the proper caregivers for childbearing women.
Birth thus evolved from a physiological event into a medical procedure. The hospital was deemed the proper setting for this procedure. Dr Joseph DeLee was a voice of medical authority who claimed that birth was dangerous and required routine medical intervention to be manageable, including anesthesia, episiotomy and forceps delivery.
During this time, in the 1920s, public health nurses with the Frontier Nursing Service in Kentucky and the Maternity Center Association in New York acquired additional training in midwifery to give maternity services to women who were being ignored by physicians due to living in medically underserved areas. They called themselves nurse-midwives. Mary Breckenridge, the founder of Frontier Nursing Service, introduced modern nurse-midwifery based on the British model to the U.S. She established the FNS as a demonstration project of complete family health care in a remote, rural area and directed it until her death until 1965. By the 1950s nurse-midwives and nurse-midwifery were well established in medical institutions and institutions of higher learning and becoming standardized. The American College of Nurse Midwives began in 1955 and solidified in 1968.
Although home birth had been the norm in the early days for nurse-midwives, they gradually moved their practices almost entirely into hospital settings. Usually they relinquished their autonomy over their practice to physicians and adopted some of their medical procedures. The benefits, however, included legal status, physician consultation when needed, a living wage and eventually prescriptive privileges, hospital admitting privileges, and insurance reimbursement.
In the 1960s, consumers began to rebel against the hospital based, medical model of maternity care. There became a growing interest in childbirth education, breastfeeding and natural childbirth. Women and families were dissatisfied with medical care and began to explore the option of home birth with midwives. The midwives attending these births were generally trained by apprenticeship and were unorganized, unregulated, illegal or not mentioned by the law. They became known as “lay” midwives and later attracted the attention of federal and state regulatory authorities and the medical profession who began to clamp down on them and in some cases arrest or prosecute them for practicing medicine without a license. Despite this, a small but steady population of families continued to demand childbirth alternatives and the midwives attending them began to organize.
By the 1950s, interventions such as anesthesia, episitotomy and forceps delivery became common in all American hospitals. The majority of women were unaware of any other way to give birth. In addition, women were forced to labor without any supportive presence of family or partners, infants were taken away from the mother at delivery and cared for in newborn nurseries, bottle feeding became the norm and babies born outside the sterile environment of the hospital delivery room were labeled contaminated and kept separately. There was absolutely no scientific rationale, evidence, studies or statistics for any of these procedures; to the contrary many of them were eventually shown to be harmful.
Meanwhile, midwifery was declared illegal in most jurisdictions and as the old “granny” midwives died out, the profession almost died with them. Midwives never succumbed completely to the campaign waged against them by the medical profession. Granny midwives in the rural south continued to serve poor and mostly black women. An amazing story of one such midwife is Motherwit, written about Onne Lee Logan who was born in 1910 in Sweet Water, Alabama, the fourteenth of sixteen children and the daughter of a midwife. She trained in midwifery by accompanying her mother to births. She eventually became the most widely respected and sought after midwife in the region. Another fantastic story about an Alabama midwife named Margaret Charles Smith is Listen to Me Good: The Life story of an Alabama Midwife.
During the 1970s the proportion of out-of-hospital births almost doubled. By sharing experience, support and education, midwives began to organize and became more and more sought after. In 1975 Ina May Gaskin published Spiritual Midwifery bringing childbirth to the public as a peaceful and intuitive experience of growth, empowerment and joy.
Ina May later established the North American Registry of Midwives, a regulating body that standardized the training of out-of-hospital birth into an apprenticeship certification program that is nationally recognized to this day. NARM has set the bar for out-of-hospital birth training and has authentically maintained the original path of apprenticeship while accommodating modern needs of standardization.
In 1982, the Midwives' Alliance of North America was founded. This organization embraces all midwives, regardless of training or credentials. However, its focus became the expansion of practice rights for direct-entry midwives who attend home births. MANA has represented midwives who steadfastly insist on autonomy and control over their practice, and the differentiation of the midwifery model of care from the medical model. 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 while standing for the freedom to practice without outside control.
During the 1990s, through MANA, certification, educational and accreditation standards were developed for direct-entry midwives. Separate organizations were formed for this purpose, as well as to legalize midwifery at state and federal levels while also working to improve interaction with the health care system. Meanwhile, ACNM began to accredit direct-entry midwifery educational programs and worked for increased autonomy of nurse-midwives through legislative and regulatory changes.
A very important scientific validation for the midwifery model of care has emerged and is contained in a massive review of 7000 clinical research studies known as “Effective Care in Pregnancy and Childbirth” also known as the Cochrane database.
In the beginning of the millennium we know that midwives offer women safe and effective care with good outcomes. More and more states have pushed for legal license for professional midwives including North Carolina. Organizations such as The Big Push for Midwives continue these efforts as more than half of American states maintain legal status for midwives.
The national average of babies born into the hands of a midwife is 7.4% and growing, in some states it is as high as 20%. Still, this rate is very low compared to that in European countries which have the best birth outcomes. Home birth continues to gain popularity and recognition with celebrity participation and promotion including Rikki Lake's Business of Being Born. Many religious sects continue to solely receive midwifery care in the home such as Mennonites and Amish where midwifery maintains its' ancient and primal roots while also becoming increasingly more mainstream every day.
“Midwife” means “with woman”. Midwives listen to women, talk with women, laugh and cry with women. Midwives are trained professionals who provide loving care. Women deserve no less and should continue to demand the best possible care for themselves and their families through supporting legislative efforts on the local, state, national and international levels. When each woman has access to a midwife, we will see dramatic improvements in maternal and infant outcomes. Blessed be the day.