History of Midwifery in the U.S.
Midwifery is an internationally recognized profession with practitioners throughout the world. In the United States, midwifery education that meets the standards of the American College of Nurse-Midwives goes beyond the scope of practice defined as midwifery to include the primary health care of women and newborns.
A Certified Nurse-Midwife (CNM) is an individual educated in the two disciplines of nursing and midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives. (American College of Nurse-Midwives, 1977).
Certification is conferred upon an individual who has met eligibility requirements for and successfully passed the national certification examination of the ACNM Certification Council, Inc. (ACC). Certification gives official recognition to an individual who has met professional standards for safe practice. This certification both protects the public and differentiates the well-educated and highly prepared Certified Nurse-Midwife or ACC Certified Midwife from those who call themselves midwives or are functioning in parts of midwifery practice without preparation in midwifery education programs that meet rigorous review for standards.
Nurse-Midwifery practice is the independent management of women’s health care, focusing particularly on pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and gynecological needs of women. The Certified Nurse-Midwife practices within a health care system that provides for consultation, collaborative management or referral as indicated by the health status of the client. Certified Nurse-Midwives practice in accord with the Standards for the Practice of Nurse-Midwifery, as defined by the American College of Nurse- Midwives. (Standards for the Practice of Nurse-Midwifery, 1993)
Beliefs
There are a number of beliefs that are central to midwifery practice and characterize the health care given by midwives. These beliefs include facilitation of natural processes and nonintervention in these normal processes unless indicated; continuity of care; promotion and implementation of family-centered maternity care; advocacy for the woman and her rights and responsibilities; education of women for knowledgeable participation and decision making in their health care and for experiencing of their bodily processes; promotion of health care, disease prevention, and the reduction of maternal and infant mortality and morbidity; the role of the midwife within the community; and the contribution of the midwife within the health care system midwife (American College of Nurse-Midwives, 1978).
Colonial Period
Midwives were considered vital to colonial community life and were treated with dignity. Special courtesies were extended to midwives, and arrangements were made to provide them with housing, land, food, and salary as payment for their services. This information is noted in town records and charters of the mid-seventeenth century. Midwifery was just one of many health care contributions colonial midwives made to the community. Often they were also nurses who tended the sick and the dying and prepared the body after death, herbalists, and veterinarians (Varney, 1980).
Religious factors plagued midwives from the beginning. Most of the early midwives came from England, where in the seventeenth century the licensing of midwives was under the auspices of the Church of England. Criteria were moralistically judgmental; they emphasized good character and granted the ability to denounce sins and to baptize. The midwives’ oath included a vow to pressure the mother into naming the true father. The results of such actions were not always appreciated. On the other hand, in the Puritan communities midwives were often suspected of witchcraft, especially if a malformed baby was born (Wertz, 1977).
Eighteenth Century
By the early eighteenth century compensation was not always adequate for the midwife; practicing mid-wifery was no longer economically feasible. This was especially true in the rapidly growing towns and cities. There was no organization or authority to establish guidelines for fees (Fox, 1969). The eighteenth and nineteenth centuries mark a time of rapid development in medical and nursing science and of discoveries and teaching pertinent to obstetric practice. These developments include the end of the Chamberlen family secret of forceps and the refinement of these instruments, technical advances that decreased the risks involved in cesarean section, pioneering efforts in obstetric anesthesia, conquest of puerperal fever, emergence of modern nursing in the 1860s, and inclusion of obstetrics in medical practice. The observations and teachings of William Smellie (1697-1763), who developed teaching manikins and kept meticulous records of his patients, identified the mechanisms of labor and refuted any number of myths and misconceptions (Wertz, 1977).
Nineteenth Century
During the nineteenth century, pioneer women crossed the plains in covered wagons, settled the ”Wild West,” and bore children with the aid of midwives who were a part of the westward movement. Despite the initial honor afforded midwives in the colonies and their importance to other segments of the population through the years, a series of factors reduced midwifery from a respected profession to one in disrepute by the early twentieth century. These factors included religious attitudes, economic demands, replacement by physicians, inadequate education, lack of organization, influx of immigrants, and the low status of women (Fox, 1969).
Era of Industrial Revolution
The industrial revolution brought an influx of immigrants from a number of European countries who formed pockets of cultural communities within cities. Each such community had its own midwives who came from the “old country.” Some were well-prepared midwives in their own country; others were not. All had the combined problems of not speaking English and not having access to the existing health care system. Their black counterparts in the rural South also could not gain access to the health care system and were poorly educated because of racism. These “granny” midwives frequently passed the practice of midwifery from mother to daughter, learned through experience, and relied heavily on patience, home remedies, and prayer, since these were the only resources available to them and the women they served. Lack of licensure, organization, and formal education programs also contributed to preventing both the urban immigrant midwives and the black rural South midwives from being a part of the official health care system (Wertz, 1977).
Twentieth Century
The low status of women in general at the beginning of the twentieth century affected the work of midwives. Norma Swenson, in her analysis of social factors affecting the history of midwifery in the United States, makes the following comments:
But the final and I think more significant point was that the status of women at the turn of the century was at a particularly low ebb. At that point in time women were regarded as economically exploitable but at the same time socially and politically incompetent, in the sense that they were perceived as being unfit to exercise good judgment concerning their own affairs or the affairs of others, and in fact were legally prevented from doing so. Paternal domination of home and society was at an all-time high.
It was then in this kind of atmosphere that midwives were outlawed and women were, therefore, in effect blamed for the appalling conditions under which mothers and babies died at that time, when in fact women were powerless to control social conditions, and coped as midwives as well as they could with circumstances which were largely the product of a man-made industrial and social revolution (Swenson, 1968).
These events and social factors combined to create a system of health care education and service to which the descendants of the midwives in the colonies, the urban ethnic immigrant midwives, the black rural midwives in the South, and the Native American midwives could not have access (Breckinridge, 1952). The first two decades of the twentieth century are notable for the recognition of woefully inadequate maternity care and subsequent actions taken to improve this care and for the establishment of two organizations, the Children’s Bureau in Washington, D.C., and the Maternity Center Association in New York City, both of which have had an immense influence on the development of maternal-infant health care and of nurse-midwifery (Varney, 1980).
In the twentieth century there was a debate over what was known as “the midwife problem.” The factors contributing to the disrepute of midwifery converged between 1912 and 1914 to make the licensing and practice of the midwife a heated issue. During this time medical schools began to include obstetrics in their curricula and obstetrics became an established medical specialty by 1930. Obstetric care began to move out of the home into the hospital, and laws were passed to regulate the practice of the indigenous midwives (Wertz, 1977).
Several schools were established as a result of the laws to regulate midwifery practice. The best known of these schools, designed to instruct the indigenous midwives in meeting requirements for practice, were the Bellevue School of Midwifery in New York City and the Preston Retreat Hospital in Philadelphia. The Preston Retreat Hospital opened in 1923, but enrollment dwindled after 1930. The Bellevue School of Midwifery existed from 1911 until 1935, when it was closed by order of the New York City commissioner of hospitals, a physician. In his opinion, changing social and medical standards rendered the school superfluous and an unnecessary expense to the city. He cited a decrease in the number of midwives as deliveries in hospitals had increased to 81 percent in New York City (Wertz, 1977).
The laws and schools to upgrade midwifery had served their purpose, and obstetric care for a large number of mothers and infants was improved. In addition, Congress passed the Sheppard-Towner Act in 1921; this legislation assigned money, administered through the Children’s Bureau, for providing better maternal-infant care. Included in this Act was the specification that public health nurses should be employed for the instruction of untrained midwives (Rooks1999).
The School of the Association for the Promotion and Standardization of Midwifery, more commonly known as the Lobenstine Midwifery School, was the first nurse-midwifery education program in the United States. The Association for the Promotion and Standardization of Midwifery was the creation of the Maternity Center Association in New York City. MCA was convinced of the need for nurse-midwives whose preparation would combine U.S. education in obstetric nursing with the education received by the professional European midwife (American College of Nurse-Midwives, 1978).
The Association for the Promotion and Standardization of Midwifery was incorporated in early 1931 by three members of the medical board of the Maternity Center Association and its general director, Hazel Corbin, R.N. Ralph Waldo Lobenstine, M.D., chairman of the medical board of MCA since 1918, was one of the charter members, as was Mary Breckinridge, director of the Frontier Nursing Service. Lobenstine worked tirelessly until his death in 1931 to bring about the establishment of nurse-midwifery services and education. The determination of the members of the for the Promotion and Standardization of Midwifery and the financial support of a group of 60 former patients and friends of Lobenstine led to the establishment of the Lobenstine Midwifery Clinic, Inc. in November 1931 (Rooks1999).
The nurse-midwifery services provided through the clinic consisted of antepartal care and patient education at the clinic, intrapartal and postpartal care in the patient’s home except when hospitalization was required for medical reasons, and postpartum checkups at 14 days and 6 weeks in the clinic. Four attending obstetricians provided medical clinics and round-the- clock consultation and, if necessary, were present in the patient’s home for delivery (Rooks1999).
Current Midwifery Programs
Graduate nurse-midwifery programs are incorporated into a program of professional studies that grants an academic degree at a master’s or doctoral level. Most master’s degree programs are 18 months to 2 years long. The curriculum for the nurse-midwifery clinical component is essentially the same in both certificate and graduate programs and is consistent with the current core competencies identified by the ACNM as requisite for the graduate of any midwifery educational program (Rooks1999).
The non-nurse basic midwifery programs, also known as direct-entry midwifery programs, are incorporated into a program of professional studies that either requires a baccalaureate degree upon entrance or grants no less than a baccalaureate degree upon completion of the program. The programs are approximately 3 years long and provide all the essential components of the midwifery curriculum as defined by the ACNM document on core competencies and the ACNM document on prerequisites to midwifery practice (American College of Nurse-Midwives website).
The majority of nurse-midwifery education programs are administratively located in university schools or colleges of nursing. A few are located in schools of medicine (department of obstetrics and gynecology), allied health, or public health. Eligibility for sitting the national certification examination of the ACNM Certification Council, Inc. includes graduation from an ACNM DOA-accredited nurse-midwifery or midwifery education program (American College of Nurse-Midwives website).
References
American College of Nurse-Midwives. (1978). Nurse-midwifery in the United States: 1976-1977. Washington, D.C..
American College of Nurse-Midwives. (2006). Program definitions. Washington, D.C. http://www.midwife.org/careers.cfm?id=86
Breckinridge, M. (1952). Wide neighborhoods: A story of the frontier nursing service. New York: Harper & Brothers.
Fox, C. G. (1969). Toward a sound historical basis for nurse-midwifery. Bulletin of the American College of Nurse-Midwifery 14:77.
Rooks, Judith P. (1999). Midwifery and childbirth in America. Philadelphia: Temple University Press.
Scholten, Catherine M. Childbearing in American Society: 1650-1850. New York: New York University Press, 1985.
Standards for the Practice of Nurse-Midwifery (1993. Retrieved May 2006 from http://www.midwife.org/display.cfm?id=610
Swenson, N. (1968). The role of the nurse-midwife on the health team as viewed by the family. Bulletin of the American College of Nurse-Midwifery 13:128.
Varney, H. (1980). Nurse-Midwifery. Boston: Blackwell Scientific Publishing.
Wertz, Richard W. (1977). Lying in: A history of childbirth in America. Schocken Books, 1977.
