by Beth Overton, © May 23, 1996

revised June 10, 1998


Midwifery is and has been practiced worldwide in all cultures and times. According to The Encyclopaedia Britannica, “The profession of midwife must be one of the oldest, being clearly recognized in the earliest books of the Old Testament and an accepted element in the social structure in ancient Greece and Rome.”1

How true. Biblical references to the practice of midwifery date back nearly four thousand years. It is mentioned in Genesis 35:17, which may be dated around 1890 BC, and then again in Genesis 38:28, within the same general time frame. Then, of course, there is the account of the midwives Shiphrah and Puah in Exodus 1:15-21, which may be dated around 1520 BC.

Consider also an early reference to midwifery dealing with first century Rome. Will Durant, discussing the state of medical pracitice during Rome’s “Silver Age” (AD 14-117), states that Quacks continued, but sound practice increased. Midwives saw most Romans into the world, but many of these women were well trained.2

These references point out just how long midwives have practiced. This paper, however, is not meant to cover the entire history of midwifery. It will focus instead on the history of midwifery in America.

The early settlers to America brought with them their customs and practices which included those pertaining to childbirth. “Not until the revolutionary period did educated doctors seek to attend births. For more than 150 years, therefore, old birth customs [from the English] prevailed in America: Expectant women looked to female friends and kin for aid and comfort–to a social childbirth–and turned to midwives for skilled attendance.”3

The long-standing rituals in birth included female friends and relatives who “came to the expectant woman to provide comfort and practical aid.”4 In addition to family and friends there was the employment of the midwife. (The name literally means “with woman,” a woman who is with a mother at birth.) The presence of a midwife offered the laboring woman the reassurance of having someone who had attended many births.

“The importance of midwives to the social order is shown in the fact that several New England towns provided a house or lot rent-free to a midwife on condition that ‘she doth not refuse when called to it.’ Non-English colonies often kept midwives on the colonial payroll. In New Amsterdam they were called Zieckentroosters, or comforters of the sick, and received liberal salaries and special privileges. The Dutch West India Company salaried midwives and gave others free houses in the city on the explicit condition that they attend to the poor upon request. The French colony of Louisianapaid midwives until 1756 and provided physicians regularly to examine the quality of their practice. Midwives in the South were usually slaves from large plantations who delivered both blacks and whites and whose services were used by smaller plantations and independent farmers.”5

 

“Before and during the Colonial period English society did not consider midwives to be part of the medical establishment or professions but saw them as performing a special social and quasi-religious function. That is, midwives did not formally train for their work, did not organize a guild to license midwives, and did not transmit skills by formal apprenticeships. Rather, midwives succeeded one another by selecting themselves, or being selected by other women to attend births.”6

Bishops in the Church of England were the first to legislate control over midwifery. Richard and Dorothy Wertz in the book Lying-In state that, “In the 17th century and before, English bishops were the only public authorities overseeing midwifery. The bishops had desired to prevent witchcraft associated with birth and to ensure that midwives were loyal to decrees of the church and state regarding birth, since midwives could baptize infants in emergencies. The bishops required that before beginning practice a midwife receive an episcopal license, which prohibited her from coercing fees, giving abortifacients, practicing magic, or concealing information about birth events or parentages from civil or religious authorities. The license also prohibited her from refusing to attend poor women.”7

Because of this infuence, civil licensing began in the colonies. Again quoting Lying-In, “In the American colonies where the Anglican influence was most strongly felt, such as New York and Virginia, civil licensing of midwives was required. In 1716 New York City required licensing for midwives in an ordinance that echoed the episcopal licenses of England. . .Such licenses in effect placed the midwife in the role of servant of the state, a keeper of social and civil order.”8

Because of their valued services, history has preserved the names of a few notable midwives. Among them were Mrs. Rebecca Fuller, the wife of Dr. Samuel Fuller. She practiced in Boston from 1630 to 1663. Upon her retirement, her services were sought by Reheboth, Massachusetts. In Boston, Ruth Barnaby delivered babies for 40 years and she began at the age of 60! Elizabeth Phillips, also from Boston, delivered more than 3,000 according to her tombstone. She practiced from 1719 to 1759.

To understand the history of midwifery, we must keep in mind that the practice of midwifery originally belonged to women. Again, doctors and medicine were not routinely a part of the birthing process. Because of this, when men in England began attending births, they called “themselves ‘male midwives’ and their medical art ‘midwifery.’ In fact, medical historians have called the years before 1750 ‘the age of the midwife,’ for doctors were few.”9

In her book, A Wise Birth, Penny Armstrong, C.N.M., describes the introduction of doctors to the birth scene in our culture. “It was the mid-nineteenth century when doctors began to enter the birthplace. Women, midwives in their number, did not exactly welcome the new-minted experts. The birthplace was their territory, after all, and as tightly held as a traditional holiday kitchen. Furthermore, doctors had little to recommend them. Frequently they were men who’d taken a few weeks off from forge or farm to attend an unaccredited school where they read textbooks and listened to lectures from others who were hardly better educcated than they. During their training, it was morally unthinkable for them to witness a birth.

“Women, by contrast, had been learning since childhood how to care for the sick, the laboring and the dying. They knew a lot in comparison to the doctors, including their limits. When they heard rumors of instruments that could be used to pull a baby out and the riveting news of the painkilling effects of chloroform and ether, they were interested.”10

To see this shift in attitude towards birth attendants (that is, to see women showing an interest in what the medical profession was boasting it could do), we must understand the context in which this change occurred. In the 1800’s many women died in childbirth. At the time all the causes were not understood. But to quote Penny Armstrong again, “Babies got stuck in their mother’s pelvis, which might have been distorted by inadequate diets. Rachitic pelvis, it’s called, and in the old days the only way to save the mother’s life was to dismember the infant in utero and remove it in pieces. Mothers died from complications of tuberculosis which, in the nineteenth century, was epidemic. Poor urban women died because their bodies were compromised by unclean water and milk, poor diet, and overwork. Rich women faltered because they subsisted on fashionable proteinless diets and because they wore corsets that grievously distorted their reproductive anatomy. All classes of women died from postpartum infection called childbed fever.”11

The history of midwifery in England compared to America is interesting. the cultures are similar, especially in earler times. In England midwifery continued to be accepted. Beginning with the 20th century many of them began to receive medical training and today they practice alongside of the medical profession.

However, in America things developed differently. From the 18th century onward, women became attracted to the promises of “modern” medicine. Doctors, with their many devices and drugs, promised to shorten labor and reduce pain. “In America. . .midwives began to disappear after 1820 except among the isolated, the poor, ethnic groups and blacks, because American doctors were more agressive and less subject to regulation than the hierarchical and disciplined English medical profession.”12

Midwifery became a victim of an otherwise beneficial free enterprise system. In the more competitive and fluid environment of medicine in America, assisting birth for American doctors became more important. It could lead to an extensive family practice and therefore they actively began to oppose women in midwifery or in medicine.

Midwives became the target of much false accusation and slander. However, again quoting Lying-In, “Historians cannot determine with finality the quality of care American midwives offered, for the data are largely absent. It seems likely, however, that a combination of environmental, cultural and social circumstances both eliminated the need for interventions in birth, which might have proved dangerous, and removed the chances that clumsy or harmful midwives were unknown and unreported. The stereotype of the midwife as a curse upon women seems unfitting for colonial midwives.”13

To summarize the situation at the end of the nineteenth century, I again quote Penny Armstorng. “But with all the experimentation, even with the combining of practical experience and new science, women died. At the turn of the century, one woman died for every 154 births. If a woman had five babies, which was common, her chance of surviving her reproductive life was one in thirty. Doctors and midwives, mothers and neighbors, with equal frequency, watched the life ebb out of women and felt babies grow cold in their hands. All had to drop their heads: God giveth and God taketh away.”14

Doctors continued to find more and more reasons to intervene in the childbirth process. For the most part, American women accepted the intervention and progressive control of the medical profession. Childbirth began to be thought of as an illness which needed the attention of a professional. Childbirth in a hospital setting began to be accepted as the norm by the 1920’s.

Government involvement in maternity health care began in the early 1900’s. Both federal and state bureaus became involved. The state bureaus primarily dealt with the problem of birth attendants. Even though fewer white middle class American women were being attended by midwives, many imigrants from Europe brought their own midwives with them and settled in major cities. As late as 1920 these midwives were attending 20-40% of all births in mid-Atlantic cities. In some cases, this meant they were practicing illegally.

The primary reason for midwives being chosen was financial. In Detriot in 1917, midwives charged from $7 to $10, a fee that included daily visits for 5 days or more. Doctors charged from $20 to $30 for delivery only. By 1930 midwives cost from $25 to $30 and doctors as high as $65. Obstetrical specialists charged $75 or more and that did not include the cost of the hospital. Many women, especially Italian immigrants, also refused to consider allowing a male attendant.

Unfortunately, some of these immigrant midwives were untrained. Dr. Josephine Baker, an experienced public health inspector in New York’s slums, described these women as “clumsy amateurs, often densely ignorant, filthy, superstitious, hidebound–all that a midwife should not be.” Had these women been trained and educated as the midwives who existed in Northern and Western Europe at the same time, there would not have been a problem.

However, beginning in the 1900’s many medical journals began to address the “midwife problem.” “The historian Frances Korbin has divided the discussants of the ‘problem’ into four groups: (1) advocates of immediate abolition of midwives, with legal prosecution of any who continued practice; (2) those who believed in eventual abolition, with careful regulation of existing midwives until enough doctors could be educated to take their places; (3) those who wished to educate the midwife until she reached the status of English and European midwives; and (4) those (mostly Southerners) who believed that, if midwives could be trained to wash their hands and to use silver nitrate drops, no more could be expected. The one thing most discussants agreed upon was that the worst birth attendants were not midwives but the general practitioners who tended to intervene needlessly in normal births.”15

State health authorities, seeing that midwives weren’t about to disappear, began with some regulations concerning basic cleanliness, forbidding medication, registration of births and use of silver nitrate drops. In the south training included training manuals and instructions on when to call a doctor. Public authorities really expected doctors and clinics to replace the midwives eventually, so no attempt was made to really train them to be professionals.

However, in some northern industrial states, experiements in more training and regulation proved more successful. Bellevue Hospital in New York City began a school for midwives in 1911, as did hospitals in New Jersey aned Philadelphia. These were schools for practicing midwives with no formal education and not “Nurse-midwives.” These trained midwives in the north significantly lowered the maternal and neonatal mortality rates. This lead some health officials to believe that this kind of training of midwives could be the answer to high mortality rates.

In this early part of the century more and more women were turning to the promises of the modern medical profession. Penny Armstrong describes the situation as follows:

“Indeed, so promising were doctors’ powers that lapses in performance were endured in good faith. The obstetrical wing of American medicine, in fact, had stumbled in the first thirty years of the century. Having drawn women into the hospital to give birth in the moderrn way, physicians were bewildered to discover that infant and maternal mortality rates did not decline. Science had uncommon trouble taming the streptococcus bacilli which, despite seemingly scrupulous sanitary measures, carried infection from sick patients to the birthing ones, as if magnietized by birth bruises and lacerations. For the first forty years of the twentieth century, urban (more hospitalized) women were much more likely to die in childbirth than their rural (more home-birthing) cousins.”16

Despite what the truth of history reveals to us, organized medicine was mostly successful in driving midwives from the birth scene. “Doctors noted with pleasure that the restriction of immigration in 1919 had prevented new midwives from arriving.”17

And according to Jessica Mitford in The American Way of Birth, “In 1900, about 50% of Ameirican births were attended by midwives; by 1935 the rate had fallen to 12%, and most of those were in the black population of the Deep South. By 1986, only about 4% of pregnant women were getting nurse-midwife care.”18

There were two reasons for the campaign against midwives from the medical profession. First, the practice of midwifery was considered “unscientific,” and therefore slowed down “scientific progress.” We must remember that in the medical and scientific fields if scientists cannot experiement and student physicians have few on whom to practice their craft, their progress is greatly hindered. Hospitals therefore perceived the practice of midwifery to be a threat to their source of patients.

The second reason was economic. “The physician who invested six to eight years on a medical education, equipped himself with every advanced technique, and charged accordingly, might well resent the midwife who learned to deliver babies from her great aunt (and charged accordingly).”19

Midwives were also the victims of bad press. As the book Lying-In reports, magazines told “horror stories replete with racial and ethnic slurs about ‘rat pie among black midwives or deformed babies allegedly delivered by Italian or Russian Jewish midwives.”20

However, it is of note that even in the obviously biased news article, “Rat Pie” (Harper’s Monthly Magazine, by Carolyn Conant Van Blarcom, Feb. 1930), the author admitted to admirable qualities in these same midwives. “They are entirely respectful and courteous about modern methods and entirely willing to obey the Department of Health Rules. More than that, they are also so eager to serve their patients well that they follow instructions with surprising faithfulness. But no amount of training, education, or laws will quite uproot their faith in the ancient remedies, that, to them, are tried and true.”21

In this same article, nine out of ten pages were used to tell of the horrors of superstitions and customs among Southern black “granny” midwives.22 Sadly, many of these midwives were driven by superstition and fear, and this was reflected in their practices, especially among those of their own subculture. However, to focus an entire article on this fact, and to characterize all in this light is, to say the least, unfair.

However, even with Van Blarcom’s attempt to slander these women, more effort was made to recognize the younger and more modern genereation of “granny” midwives. In referring to a Department of Health classroom of these younger women, she says the following.

“The rows of pupils with tidy heads and hands, immaculate in their wash uniforms, might have been the staff of any visiting nurse association. There were no leathery, rheumy-eyed old crones. Only alert young women. Their bags, with washable linings and appropriate contents, conformed to State Department of Health requirements. . .The quizzing and responses were intelligent and practical and showed that the midwives in that group had a good working idea of what could and should constitute their service; and more importantly still, under what conditions they should summon a doctor and what they definitely could not do for their patients.”23

Nurse-midwifery appeared in the 1930’s. It stemmed from the profession of nursing rather than midwifery. Their emphasis was assisting doctors in their profession. Nurse midwives did provide supervision for rural immigrant midwives.

Nurse-Midwives is another subject of interesting comparison to Europe. As explained in the book The American Way of Birth, “In Europe, there is no such creature as a ‘nurse-midwife’–to European ears, the term conjures up a strange hybrid for which there is no known equivalent. As Dr. Marsden Wagner of the World Health Organization put it, midwifery and nursing are two entirely separate (and highly regarded) professions, each trained in specific skills. The requirement that a midwife must first get a degree in nursing would be akin, he said, to demanding that a plumber in order to be licensed should first pass the necessary tests to qualify as a carpenter.”

It wasn’t until the 1940’s that women began to question the necessity of drugs and the “managing” of childbirth. Since that time, as more and more women have sought a more natural birth experience, we have seen a growing need and desire for the services of qualified midwives.

Perhaps as a surprise, what the medical profession first promised (a safer and easier childbirth) is being found by many women in a return to the “old ways” and trusting more in nature and the way God designed our bodies to give birth. Or, as it is stated in Lying-In,

“For the first time many women’s values diverged significantly from the meidcal consensus and generated some new birth rituals: birth education, relief of pain through breathing exercises instead of drugs, and a desire to humanize birth by allowing the presence of husband or friend.”24

Today midwives are governed by the individual laws of each state. According to the Texas Midwifery Basic Information and Instructor Manual, the first laws [pertaining to midwifery] in Texas date back to 1925. These were with regard to registration, the filing of birth certificates, a blood test for syphilis, and drops in the eyes of the newborn to prevent infection.

Also, in 1983 a law was enacted which was called the Lay Midwifery Act, Texas Civil Statutes, Article 4512i. This law delineated the scope of practice and voluntary educational preparation for those attending a birth. The term “lay” was deleted in an amendment of 1991 and mandatory educational requirements were defined to be effective as of September 1993. In 1993 this Act was further amended and the Midwifery Board was given investigative authority.

And so the history continues to be written. The profession of midwifery has come under much scrutiny over the centuries. Despite bad press and much persecution women still turn to midwives to birth their babies. As far as the law is concerned, the tide has turned different directions and will probably continue to do so. But whatever the outcome politcally, women will mostly continue to trust their own judgment concerning the birth of their children. In doing so, many of these women will continue to do as they have for generations, which is to turn to other women, midwives, for their experience and non-medical approach to childbirth.

 


ENDNOTES

 

  1. —, The New Encyclopaedia Britannica, Micropaedia, Vol. 8, p. 114.

  2. Durant, Will, The Stroy of Civilization, Vol. III, “Caesar and Christ,” p. 312.

  3. Wertz, Richard W. & Dorothy C. Lying-In: A History of Childbirth in America, p.1.

  4. Wertz, p. 2.

  5. Wetz, p. 8.

  6. Wertz, p. 6.

  7. Wertz, pgs.6-7.

  8. Wertz, p. 7.

  9. Wertz, p. 6.

  10. Armstrong, Penny, C.N.M. & Feldmena, Sheryl, A Wise Birth, p. 73.

  11. Armstrong & Feldman, pgs. 71-72.

  12. Wertz, p. 282.

  13. Wertz, p. 13.

  14. Armstrong & Feldmean, p. 75.

  15. Wertz, pgs. 212-213.

  16. Armstrong & Feldman, p. 77.

  17. Wertz, p. 216.

  18. Mitford, Jessica, The American Way of Birth, p. 166.

  19. Armstrong & Feldman, p. 80.

  20. Wertz, p. 216.

  21. Van Blarcom, Carolyn Conant, “Rat Pie,” Haper’s Magazine, February, 1930, p. 323.

  22. Van Blarcom, “Rat Pie,” p.331.

  23. Mitford, p. 182.

  24. Wertz, p. 283.                                                        

 


BIBLIOGRAPHY

—, Texas Midwifery Basic Information and Instructor Manual. Austin, TX: Texas Department of Health, 1995.

—, The New Encyclopaedia Britannica, Micropaedia, Vol. 8. Chicago, IL: Encyclopaedia Britannica, Inc., 1995 (15th ed.).

Armstrong, Penny, C.N.M. & Feldmena, Sheryl, A Wise Birth. New York, NY: William Morrow & Company, Inc., 1990.

Barker, Kenneth (General Editor), The NIV Study Bible. Grand Rapids, MI: The Zondervan Corporation, 1985.

Durant, Will, The Story of Civilization, Vol. III, “Caesar and Christ.” New York, NY: Simon & Schuster, 1944.

Mitford, Jessica, The American Way of Birth. New York, NY: Dutton, an imprint of New American Library, a division of Penguin Books USA Inc., 1992.

Van Blarcom, Carolyn Conant, “Rat Pie,” in Harper’s Magazine, Concord, NH: Harper & Brothers, February, 1930.

Wertz, Richard & Dorothy C. Lying-In: A History of Childbirth in America. New Haven, MA: Yale University Press, 1989.

 


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by faith gibson, C.P.M., community midwife