A Brief History of Midwifery in America
Since the dawn of time to the present, across all cultures, midwives have attended the majority of the world’s women during childbirth. Carrying the knowledge of birth and death, women’s sexuality, healing methods and medicinal plants,
A Midwife should have a hawk’s eye, a lady’s hand, a lions heart”
…From a 16th Century Midwifery Text
One of the world’s oldest professions for women is midwifery. Since the dawn of time to the present, across all cultures, midwives have attended the majority of the world’s women during childbirth. Carrying the knowledge of birth and death, women’s sexuality, healing methods and medicinal plants, “a Midwife should have a hawk’s eye, a lady’s hand and a lions heart” (16th Century Midwifery Text). Midwives are referred to in The Bible, The Hebrew Midwives Shifrah and Puah answered to the call of Hashem, instead of abiding by the law of the Pharoh to kill all firstborn males, and bravely saved the newborn Jewish males, thus carrying on the Hebrew nation. Some have speculated that Mary The Holy Mother, was attended by a midwife (whose name remains lost to time) when she gave birth to her divine son Jesus the Christ. There have been many famous women who made their political and social mark on society who had their start as midwives; including Margaret Sanger, founder of the the birth control movement in America and the American Socialist activist Emma Goldman.
During the 15th and 16th Century Inquisition, midwives were burned at the stake for being “the early companions of The Devil” (The Witchammer, 1487) and for not complying with the Frankfurt Midwifery Code established by the Catholic church which was in effect for 130 years. These unsanctioned rituals seemed like witchcraft to these zealot priests (Judith Rooks, Midwifery and Childbirth in America. Philadelphia: Temple University Press, 1997, p.16). In Europe, midwifery care became established as part of the health care system early on in in the 18th and 19th centuries. In England, most midwives were trained as both nurses and midwives. Mary Breckinridge immigrated from England to the Colonies and was a nurse and midwife, and was the first to create a training program for midwives in the 1920s, Frontier School of Midwifery and Nursing Service (whose graduates became the forerunners of today’s Nurse-Midwives), riding horseback into the Appalachian Mountains of Kentucky to care for coal-miners wives and children. Their skills in both nursing and childbirth was valuable when caring for these people who suffered from a broad range of illnesses resulting from poverty and malnourishment.
The benefits of midwifery were recognized early on in Europe, as the decline in maternal deaths from sepsis or “childbed fever” and infant mortality declined in England and Wales, compared to Scotland and Ireland where it did not after the implementation of The Midwives Act in 1902 in England and Wales which restricted midwives from preparing the bodies of the dead for burial and reduced spread of bacteria when they attended women in childbirth. During the end of the 19th century, affluent women were attended by physicians (often accompanied by midwives) during their births at home. The “lying-in hospitals” were created for the masses of poor women; they were overcrowded and unsanitary, and many died until the knowledge of the importance of hand-washing was discovered and promoted by Semmelweis. At the turn of the 20th century in America, one of the platforms of the Suffragettes who campaigned for women’s right to vote was also the “right” for all women to have “painless” childbirth, following the trend set by Queen Victoria of England.
In North America, during the first 250 years of history of the colonies, midwives attended the majority of births, in absence of physicians and were “highly respected members of their communities” (McCool and McCool as quoted in Rooks, p. 18). Where there were no trained midwives, untrained women met the need, and the need was great, due to lack of family planning methods. The history of the profession of midwifery in North America is distinct from it’s development in other parts of the Western world. Due to America being a colony, immigrant women who learned their trade in their country of origin passed down their knowledge and skills to younger generations of midwives, in absence of established schools or governmental regulations. Thus two types of midwives developed in the United States: Nurse-Midwives (who are trained in both nursing and midwifery) and Direct-Entry Midwives (who are not nurses). Nurse-Midwifery became more accepted by the medical community and thus there are more nurse-midwives than direct-entry midwives practicing in the U.S. today.
Slave women brought over on ships from West Africa also brought with them folklore, traditions, superstitions and practices and handed these down to each new generation of midwives and mothers. Most plantations had their own women who attended births of both slave women and slave-master’s wives alike and cared for their babies and children. After emancipation, Black women who became midwives often felt “they were called by the Lord to do so either through visions or dreams” (Robinson, 1984, as quoted in Rooks, p. 18). Many women of today feel this calling and so enter the profession. Granny Midwives were older women beyond the age of childbearing themselves, either Black of White; some were designated to be midwives by their communities and others felt spiritually “called” to the profession. They learned through apprenticing themselves to experienced midwives, many times a member of their own family. Most of the women they attended had little education and little or no access to medical care “thus the Grannies took care of complications as well as normal deliveries” (Rooks, p. 7). Ironically, half of all births were attended by midwives at the turn of the 20th century; immigrants from Europe brought their midwifery tradition with them like the midwives who were brought over on the slave ships from Africa. The tradition of “Black Granny Midwives” continued in the rural South half way into the 20th century, they provided much simpler care and attended both Black and White women, according to Judith Rooks in her book, Midwifery and Childbirth in America. Many Grannies were trained through public health departments in the mid-twentieth century to “upgrade” their skills. Similarly, in the late 20th century and early 21st century, ministries of health in the lesser developed regions of the world called for upragding of Traditional Birth Attendants skills to be able to manage complications of childbirth, an approach which some say has failed. The world’s Maternal Health experts have concluded that only access to skilled health professionals–midwives, nurses and doctors, will lower the rate of maternal deaths worldwide. This is good news, as the benefits of midwifery care are slowly becoming recognized once again.
At the turn of the 20th century; immigrants from Europe brought their midwifery tradition with them like the midwives who were brought over on the slave ships from Africa. The tradition of “Black Granny Midwives” continued in the rural South developed regions of the world do the same with training Traditional Birth Attendants ). Few Grannies still practice today, however International Center for Traditional Childbearing is restoring the traditional healers and midwives in the Black community, their mission is to cultivate indigenous midwives and doulas of African-American heritage to address the alarming disparities in African-American infant and maternal mortality. Black midwives such as Jennie Joseph, LM, CPM in Florida is serving women of color at her birth center and training midwives of color through her school. Also, organizations such as Mama Sana/Vibrant Woman in Austin, TX, support the individual and collective empowerment of low-income mothers of color while also improving pregnancy and birth outcomes for communities of color in Austin, by increasing access to midwifery care and Doula support. Spearheaded by Latino midwife and community activist Paula X, Rojas, LM, CPM, Mama Sana/Vibrant Woman are reaching women of color and providing training opportunities for women from their communities to become doulas and midwives.
As Julie Chinyere Oparah States in her essay in Birthing Justice: Black Women, Pregnancy and Childbirth(Routledge, 2015), “the struggle for birthing alternatives is inseparable from struggles for racial, economic and social justice and the fundamental transformation of global maternal-care systems.” (Page 13). As White women from the counter-culture in the 1960s and 70s were building the “Alternative Natural Childbirth Movement,” Black activists were involved in the Black Power and civil rights movements which worked to address social conditions and institutionalized racism which contributed to “Black women’s vulnerability to pregnancy complications” and infant mortality. “In particular, civil rights activists focused on desegrgating hospitals and fighting for their inclusion under the Civil Rights Act of 1964”, which prohibited funding to any institution which denied Black people access to treatment. Also, according to Oparah, “Black nationalists established autonomous health clinics and challenged racism in the medical profession, as well as exploitative research” ( such as The Tuskeegee Study and the Hela cell research). “While working on access to quality healthcare services for [poor women of color], many Southern and immigrant Black women continued to birth against the grain drawing upon ‘motherwit’–intergenerational mothers’ wisdom– to guide their birthing decisions.” (Oparah, page 13). Thus the idea that White counter-culture women revived the profession of midwifery which had become extinct with the Black Granny Midwives mid-20th century, is a narrative that needs to be retold, according to Julie Chinyere Oparah, Dr. Alicia Bonaparte,Ph.D., and other sociologists and historians who study childbirth among women of color in America.
Persons fitting the WHO description of a TBA have been called “Lay Midwives” or “Granny midwives” in the U.S. Apprenticeship was the traditional route of entry into the profession, and still is in many parts of the world. WHO calls informally educated women who attend births Traditional Birth Attendants (TBAs) or Indigenous Midwives. A few fitting this description still practice today in America. Called “Partera” in the Southwestern United States, they attend Latino women. There are also Native American midwives who attend members of their own tribe. These Indigenous Community Midwives are the keepers of knowledge and art of childbirth and pass their wisdom down to younger generations of aspiring midwives, yet they do not have formalized training, licensure or certification. WHO tries to keep a clear distinction between midwives and TBAs. Midwives, by contrast, have successfully completed a formal course of study and are qualified to be registered or licensed in the jurisdiction in which they practice. However, the U.S. is unique in that these two definitions do not fully encompass all the types of women who help other women during childbirth; many do not fit into either definition of Midwife or TBA (Rooks, p.7). In modern industrialized countries, professional midwives continue to deliver the majority of the world’s babies, and childbirth at home is still the most common setting for birth. In fact, the development of more midwives is a recommendation called for by WHO, FIGO, ICM and other international public health organizations to reduce maternal mortality worldwide.
During the 1940s through the early 1960s in America, women knew very little about childbirth; there was no formalized childbirth education classes as there are today, and they were told to put their trust in the expert doctors. Women gave birth heavily sedated (“Twilight Sleep”) and alone as fathers were not allowed in the delivery room. Babies were heavily drugged as well and often had to be pulled out of the birth canal by forceps, metal spoon-like devices which had originated in England in the 1800s with The Chamberlain Brothers. Babies were held upside down like a fish, spanked on the bottom to be made to cry, and were immediately separated from their mothers and placed in assembly-line style nurseries. Babies were fed artificial baby milk (which was a nasty concoction mixed up in kitchens, not the commercial formula we know today), as women were discouraged from breastfeeding, and were given drugs to make their milk dry up. For poor factory workers, there was no alternative but to wean early to return to the assembly line, and wealthy women considered breastfeeding animalistic, caring for babies tied them down, and kept them from more important “social welfare” endeavors, some of which would be considered eugenic by today’s standards. Groups such as The Maternalists did a lot to discourage breastfeeding and promote the use of artificial baby milk, contributing to maternal and infant mortality.
The Resurgence of Midwives and Homebirth in America
In the late 1960s and early 70s against this backdrop women began to yearn for something more humane when they gave birth. Encouraged by a few maverick doctors: Leboyer, Odent, Lamaze, Dick-Read, Bradley, and others, who promoted conscious relaxation and mothers being awake, and having fathers (and siblings) present at the birth. Women who had themselves given birth to their babies at home began to help other women do the same, and they became the first generation of “lay midwives”. These women often learned by assisting family doctors who attended births at home and reading midwifery texts from other countries. Many did not consider themselves midwives when they began. They were just helping their friends have the same beautiful experiences they had had. The homebirthers were part of a larger feminist women’s healthcare movement which empowered women and girls to learn about their bodies. Fledgling women’s health collectives, feminist women’s health centers and groundbreaking books were published such as Our Bodies Ourselves. More and more women began to reclaim their births. The Natural Childbirth Movement in America and the resurgence of birth with midwives was also a part of the “Back to Nature Movement” whose proponents sought to live in harmony with the earth and their lifestyles hearkened back to simpler time. The counter-culture generation who were in their teens and twenties during this era were disillusioned with mainstream society and social conventions and sought to create a Utopian world “off the grid” and outside of social norms. It was in this context that women started giving birth to their own babies without professional nurses or doctors in attendance, surrounded by friends. This phenomenon was occuring all over the country though people didn’t know that it was being done elsewhere until organizations such as The Association for Childbirth At Home International (ACHI) and Informed Homebirth (IH) were started by the first generation of lay midwives and the classic book on childbirth at home Spiritual Midwifery was written by Ina May Gaskin and The Farm Midwives.
The Future of Midwifery and Homebirth in America
According to a report by The Future of Health at the UCSF Center for Health Professions, The Future of Midwifery: Charting A Course for the 21st Century, “for the past 40 years, the rate of all out-of-hospital births in the United States has been approximately 1 percent of all births”. The report also revealed that there are few midwives from communities of color. More efforts to recruit midwives from ethnic communities is needed.
According to authors of a 2010 study comparing planned and unplanned births published in the Journal of Obstetrics and Gynecology, “one basic difficulty in analyses of home births in the United States has been that, given the infrequency of home birth, data for a large population are typically needed to reliably explore trends or examine . Also, until recently, birth certificate data regarding place of birth did not distinguish between planned and unplanned home births. This article uses a new measure added to the U.S. Standard Certificate of Live Birth (2003 Revision) that identifies planning status, enabling the profiling of both planned and unplanned births that ultimately occur at home in the 19 states that have adopted the revised birth certificate”. This new data will include the type of birth attendant, making it easier to track the numbers of midwife-attended births and types of midwives. The authors found that: Of the 11,787 home births with planning status recorded in the 19 states studies, 9,810 (83.2 percent) were identified as planned home births. The percentage of all births that occurred at home that were planned varied from 54.2 percent to 98.1 percent across states.[Declercq E, MacDorman M, Menacker F. 2010. Characteristics of planned and unplanned home births in 19 states. Obstetrics and Gynecology 116(1):93-99.] Download Abstract
Social Media and Midwifery Awareness
The word “midwife” still sounds archaic to many people in the United States today. However, thanks to recent media including Rikki Lake’s film The Business of Being Born and Debra Pascali-Bonaro’s film “Orgasmic Birth”, Ken Schneider and Marcia Jarmel’s video “Born In the USA”, Jennifer Block’s book Pushed: The Painful Truth About Childbirth In America and other media, the word “midwife” is re-emerging in the American lexicon as is as is a renewed interest in “natural childbirth” and increased awareness of the crisis in maternity care in the U.S. which has led to more and more parents choosing midwives and natural childbirth. Thanks to organizations like Childbirth Connection (formerly The Maternity Center Association founded in the early 1900′s in New York) a research and policy organization, and The Coalition for Improving Maternity Services (CIMS) a collaboration between leading maternity care associations and perinatal researchers, “Natural Childbirth” has been reinvented for the 21st Century as “Mother and Baby Friendly Care”, terms coined by a couple of leading organizations to promote evidence-based mother and baby centered maternity care including WHO and UNICEF. The Baby-Friendly Hospital Initiative (BFHI) was developed by UNICEF and WHO to promote breastfeeding and mother-infant attachment and provides guidelines for hospitals to implement 10 policies which optimize breastfeeding success and promote maternal-infant bonding. The Mother-Friendly Childbirth Initiative (MFCI) was developed by the Coalition for Improving Maternity Services (CIMS) a coalition of leading maternal health organizations, individuals and researchers, who outlined 10 steps to achieve optimal outcomes for mother and infants, including midwifery care. It has been said that “nothing is so powerful as an idea whose time has come”, and now is the time for mother and baby friendly care. Midwives have been providing this approach to caring for mothers and infants since time immemorial. Childbirth with midwives is no longer outmoded fad of the flower children of the counter-culture. People of all backgrounds choose midwifery care. Though biases and misconceptions remain in in American culture towards midwives. In the 21st century, more hospitals are offering birth with midwives, and expectant parents are choosing alternative settings such as their own home or birthing centers, and these numbers are expected to increase as the positive results of midwife-assisted births are more broadly recognized. The Big Push for Midwives is a national legislative campaign that seeks to legalize Certified Professional Midwives in all 50 states. When this happens, there will be increased access to midwives and out-of-hospital birth options.
As steadfast guardians of life and blenders of the best of science and tradition, midwives hold the promise of a world of health for all in their hands.”-Robbie David-Floyd, Ph.D., Medical Anthropologist”
Resources for Professionals: Midwifery
- Graphic of Birth Places and Types of Providers in the U.S : Birth Settings in the U.S. (from Institute of Medicine)
- Watch the You Tube Video: Midwives Addressing Health Disparities
- Midwife Robin Lim, CNN 2011 Hero of the Year: Acceptance Speech ( with Anderson Cooper) [Video] Watch Now
- Midwife Robin Lim, CNN 2011 Hero of the Year: Backstage Interview (with Dr. Sanjay Gupta) [Video] Watch Now
- Childbirth Connection: “Midwifery Care Evidence-Based Practice Brief” Download
- Childbirth Connection: “Imperative to Train More Midwives” by Carol Sakala, Ph.D., MSPH Download
- UCSF Pew Report: The Future of Midwifery (1999): Download
- Scope of Practice for California Nurse-Midwifery: California Board of Registered Nursing, The California Nurse-Midwifery Scope of Practice
- Business and Professions Codes for Licensed Midwifery: California Medical Board Division of Midwifery Licensing, The California Licensed Midwifery Practice Act of 1993
- Statistics on Outcomes of California Licensed Midwives/California Medical Board Annual Report – Summary of Medical Board activity, summary of physician and surgeon licensing and complaints filed, and statistics on birth outcomes of non-nurse midwives MBC-2011-2012 Annual Report [see page 4].
ABOUT THE AUTHOR
Cordelia Hanna, MPH, CHES, ICCE, CLE, CBA, has been a midwifery activist and student of childbirth & midwifery, and public health since 1991. She has attended births in hospitals, birth centers and homes and has been a primary midwife under supervision and has assisted several homebirth midwives in Los Angeles and Orange Counties. She is also a hospital labor companion and monitrice and postpartum doula and and has taught childbirth preparation classes to hundreds of expectant parents for two decades. Hanna has a Masters in Public Health in Health Education and Promotion/Maternal Child Health from Loma Linda University and is an ICEA-Certified Childbirth Educator, CAPPA-Certified Lactation Educator, and ALACE-Certified Birth Assistant and NCHEC-Certificated Health Education Specialist. She is passionate about promoting mother and baby friendly care in the U.S. and working to reduce perinatal health disparities in America and Africa. She worked for nearly a decade on the Black Infant Health Program at the Pasadena Public Health Department in Pasadena, California. This is state funded program to reduce African-American maternal and infant mortality. Presently, as Executive Director and Founder of The Association for Wholistic Maternal and Newborn Health, a non-profit organization in Los Angeles, and directs the Community-Based Doula Program which provides low cost and free doula support to low income mothers. She also trains Community Perinatal Health Promoters. She is the mother of two children who were born at home with midwives, breastfed, family-bedded and attachment parented, who are now bright and capable young adults and a grandmother of two girls. For more about Cordelia, go to her website.