The Birth of Midwifery
As women gave birth, they sought and received care from supportive others. At an unknown point in the cultural evolution, some experienced women became designated as the wise women to be in attendance at birth. Thus, the profession of midwifery began. Indeed, as historians have noted, midwifery has been characterized as a social role throughout recorded history, regardless of culture or time. Biblical recognition of the functions of midwives included several verses recounting the experiences of two Hebrew midwives who refused to kill male infants in defiance of the King of Egypt (Exodus 1:15-22). Other verses in the Bible also make passing references to midwifery attendance at birth, implying that it was ubiquitous (Genesis 35:17; 38:28). Historians have found the practice of midwifery referred to in other papyri as well as in ancient Hindu records. In Greek and Roman times, midwives functioned as respected, autonomous care providers to women during their reproductive cycles. Some qualifications for the practice of midwifery began to evolve during this period. For example, in Greece the midwife was a woman who had born children herself. This requirement has remained a commonality in the practice of midwifery throughout several cultures and exists even today. "Midwife" is a word which in English was translated to mean "with woman", implying the supportive, not interventive, functions of the practitioner. In French a midwife is a sage femme, or a "wise woman". A general thread in all of the references regarding ancient midwifery was support of the woman in labor. Labor was perceived as a basically natural process. The profession of midwifery continued without major changes throughout the centuries, even through the Dark and Middle Ages. In their practices, midwives routinely used herbs and potions, as forerunners of today's modern pharmaceuticals. The midwives of these centuries generally continued to learn by the apprentice model. As an apprentice, skills and knowledges were shared from generation to generation but without the development of a formalized system of university education. Therefore, midwives did not benefit from the scientific inquiry that developed early in medical schools. Eventually midwifery in most affluent countries developed formalized programs, although apprenticing still may be part of some. Midwives are the most common birth attendant in the world. The average child born in this world is born into the hands of a midwife.
A brief history of Midwifery From an unpublished work: Author unknown - Circa 1992 Midwives date back to references in the old testement (Genesis 24). Egypt: In Egypt midwives jealously guarded the secrets of their profession - therefore very little of practical value was handed down in writing. Greece:
In ancient Greece midwives were required by law to have had children themselves. 1500:
The "Sloan Manuscript No. 2463" was one of the earliest works on midwiferey. Echarius Roesslin (Frankfurt) published ³Rosegarten´ a guide for midwives and physicians. In the 1500s, childbirth was viewed as one of the ³diseases of women´. 1600:
One of the first schools for midwives was in the early 16 century at the Hotel-Dieu, Paris. The first woman to write a text on midwifery was Louise Bourgeois (1563 - 1636). She was the wife of an army surgeon. 1720:
Maubray gave criteria for requirements of a midwife - not fat, considerate, grave, patient, pleasant and follows advice. Edmund Chapman (1680-1756) the second public teacher (after Maubray), who wrote: ³ ... one of the most noble ... operations ... requires judgment for there is generally one and often two lives snatched from the jaws of death ...´ . 1731:
William Giffard published ³Cases of Midwifery´, surgeon and man-midwife, which gave accounts of practical experiences, including the use of forceps. There were also district advances around this time. 1735:
William Smellie (1698-1763) believed to be a single individual with most profound effect on midwifery. Around 1735 recorded the use of forceps in France. 1742 and Smellie became an instructor of midwifery. His published works include: 1
1751 A treastie on the theory an practice of midwifery 1754 A collection of cases and observations in midwifery 1764 A collection of peternatural cases and observations in midwifery .
1752:
Sir Richard Manningham (1690-1759) established General Lying-in Hospital and later, Queen Charlotte¶s Hospital. Previously he had supplied beds in a rented house next door to his own house. he taught by using a manikin. During the 18th century midwifery became respectable as a profession for men, due to William Hunter (1718-83). Before the end of the 18th century there were six or seven maternity hospitals as well as maternity wards attached to General hospitals. Also around this time Alexander Gordon (1752-99), of Aberdeen (Scotland), made the discovery that it was Doctors and Midwives that actually carried infection from one patient to another and declared that if the patient¶s clothing and bed linen were burned and Midwives and Doctors carefully washed themselves, changed their clothing and fumigated the infected clothing, this would contain infection. Many doctors and Midwives took exception to this advice. The history of Midwifery has been a long struggle between firstly, a male dominated priesthood and, subsequently a system of organised medicine also controlled by men, and a women¶s community-based network of helping and healing. In the 19th century the rising middle classes came to prefer obstetric care to the traditional care from midwives. Right through the century, however, the poor had recourse to midwifery amongst the working class. There was a resistance to attempt to organise midwifery and make it a profession in case it affected the lucrative middle class doctor¶s pracises. 1830: Augustus Granville - founder of the Obstetrical Society of London said that women were ³unsuited by nature for all scientific mechanical employment´. 1840:
Several medical schools and colleges added midwifery to the curriculum. 1850:
Royal College of Physicians and Surgeons award diplomas in midwifery for the first time. Many obstitricians believed they would never receive rightful status and many were still untrained. 1862:
Nightingale Ward, King¶s College Hospital opened to train nurses in midwifery. First Health Visitors were appointed by Manchester and Salford Ladies Health Society. The aim was to popularise sanitary knowledge in the home. 1881:
Midwives institute (later became the Royal College of Midwives) was founded and began arguing for increased and better training. 1892:
Buckingham County Council appointed three µLady Missionaries¶ to go into the community and give instruction on child welfare and hygiene. This was based on Florence Nightingale¶s views. 1902:
Midwives Act becomes law. Midwifery became an established profession in Britain. Midwives had to undergo supervised training and registration. At the turn of the century there was very littel antenatal care of the pregnant woman. A woman was rarely examined until labour was underway. Although she was given information about general health, diet, clothing etc. 1915:
Compulsory notification of births. There was also the appointment of a lot more Health Visitors as Medical Officers of Heatlh. They were essential in teaching the proper feeding and care of children. Improvements in living standards of families with young children were sought. 1919:
Newly established Ministry of Health and the Board of Education made conditions for the training and appointment of Health Visitors. 1946:
The National Service Act opened a new chapter in the history of public health. Here was the promise of a comprehensive medical service for the whole population. It was a service that provided a new look not merely at the hospitals, private practitioners and dentists, but nurses, midwives and health visitors. Also in 1946 a working party was appointed to consider the position of general nurse training.
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Its report was revolutionary and highly contriversal. A year later a similiar report was appointed to consider the recruitment and training of midwives. Its report was less arresting but some of its recommendations proved acceptable to the ministry. 1959:
For those who wanted to go further than the rest a new conception of nurse training had been evolved as a result of collaboration between Hammersmith Hospital, Battersea College of Technology and the Queen¶s Institute. This was a four year integrated course of nurse education. 1967:
Teachers of Nursing Act - allowed qualified teachers who were also registered nurses to be admitted to the register of nurse tutors. A pilot study for new midwifery training course was set up. It replaced the previous two part courses by about 1970. In mid 1975 training was offered at 116 schools. The course lasted for one year for RSN and RSCN and eighteen months for enrolled nurses and two years for those without previous training. 1975:
The number of midwives was reported to be 16,550. The training and practice is controlled by the Central Midwives Board on behalf of the Government. 1976:
Contraception became an inegral part of the NHS and contraceptive treatment, advice and supplies now available to women irrespective of age or marital status. 1979:
The Nurses, Midwives and Health Visitors Acts of 1979 and 1992 established the UKCC and the four National Boards to regulate nursing, midwifery and health visiting professions. 1983:
Three statutory bodies controlled the practice, education and training of midwives prior to the handover of functions to the new statutory bodies on 1st July 1983. They were: y y y
The Central Midwives Board. The Central Midwives Board for Scotland. The Northern Ireland Council for Nurses and Midwives.
1989:
The strategy for Nursing produced the first major changes in nurse and midwifery education for over fourty years. Project 2000, and the implemention of a new career structure for nurses, midwives and health visitors which would reward clinical skills they acquired in relation to the responsibilities they take. It concentrates on five main issues. 1. 2. 3. 4. 5.
Nursing practice. Manpower. Education. Leadership. Management.
and was formulated to assist the professions in meeting changes in helath and health care. 1989:
White paper W orking for patients. There were three other key policy initiatives y y y
C aring
for people (1989) H ealth of the Nation (1992) P atient¶s charter (1991)
1991:
The Midwives Rules, UKCC.1992:T he scope of P professional practice, UKCC. T he code of conduct for the nurse, midwife and health visitor , UKCC.
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A Short History of Midwifery
Highlights in the history of a very old profession, with references for more information elsewhere. "Well-behaved
women rarely make history. " (Laurel Thatcher Ulrich) If you don't have time to read the whole story of midwifery as presented here, click on the part that interests you the most:
I. Long Ago and Far Away Midwives have been part of the human experience for as long as we know."The ancient Jews called her the wise woman, just as she is known in France as thesage-femme, and in Germany, the weise frau and also H ebamme or mother's adviser, helper, or friend. The English 'midwife' is derived from midwife, or with-woman"(J.H. Aveling). The Latin term cum-mater and the Spanish and Portuguese term comadre, have the same meaning: with woman. The midwife is mentioned 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." In ancient times and in primitive societies, the work of the midwife had both a technical or manual aspect and a magical or mystical aspect. Hence, the midwife was sometimes revered, sometimes feared, sometimes acknowledged as a leader of the society, sometimes tortured and killed. The midwife had knowledge and skill in an area of life that was a mystery to most people. Since women had no access to formal education, it was widely assumed that the midwife's power must come from supernatural sources, such as an alliance with the devil. During the Middle Ages, a frenzy of witch-burning, promoted by both church and civic authorities, was responsible for the killing of up to several million women, many of whom were midwives and healers. In her book on Woman as Healer , Jeanne Achterberg describes the witch-hunts as "an evil that surpasses rational understanding. Here was, indeed, the worst aberration of humanity, and it trickled down the hierarchy of authority." Today, in much of the world, professional midwives are responsible for attending women in labor and birth. In fact, in the countries with the best pregnancy outcomes, midwives are the primary providers of care to pregnant women. However, midwives are still prosecuted and persecuted for following their vocation, although not in the extreme way that characterized the Middle Ages.{mospagebreak} II. The Beginnings of Midwifery in America In the U.S., midwives, like physicians, practiced without specific education, standards, or regulations until the early part of the th 20 century. Although detailed statistics were lacking, the evidence available showed that midwives' patients were less likely than physicians' patients to die of childbed fever or puerperal infection, the most significant cause of maternal morbidity and mortality at the time. One American midwife and healer named Martha Ballard, who practiced in Maine between 1785 and 1812, kept a diary of her life and work. On the basis of this diary, Laurel Thatcher Ulrich wrote a portrait of Martha Ballard's life and work, A Midwife's Tale, published in 1990. Ulrich's book won a Pulitzer Prize and was made into a film. To explore more about Martha Ballard, visit www.dohistory.org, or read Ulrich's fascinating account by clicking on the title to order. To find other books about traditional midwives in America, go to the "homage to our foremothers page" on Marilyn Greene's midwifery site. In the half-century between 1770 and 1820, upper-class women in American cities started to favor "male midwives," or physicians. According to Catherine Scholten in her book, "Childbearing in American Society: 1650-1850," "the presence of male physicians in the lying-in room signaled a general change in attitudes toward childbirth. With changing conditions of urban life, new perceptions of women, and advancements in medical science, birth became increasingly viewed as a medical problem to be managed by physicians. At the same time, because medical training was restricted to men, women lost their positions as assistants at childbirth, and an event traditionally managed by a community of women became an experience shared primarily by a woman and her doctor." However, since the interest of the male midwife was an economic one, it did not extend to lower-class women, black women, or immigrants. During the nineteenth century, midwives continued to care for these women. As medicine gained legitimacy and power toward the end of the nineteenth century, it called for the abolition of midwifery and home birth in favor of obstetrics in a hospital setting, a goal that it almost accomplished. In 1900, midwives attended almost half of all births; by 1935, the number had decreased to 12.5%. Midwives were portrayed as dirty, illiterate, and ignorant, and women were convinced that they were safer in the hands of doctors and hospitals. After providing care to women during the formative decades of our country, th midwives were effectively stamped out in the early years of the 20 century.{mospagebreak} III. The Medicalization of Childbirth Physicians trained in the specialty of obstetrics and gynecology declared themselves to be the proper caregivers for childbearing women, and the hospital was deemed to be the proper setting for that care. Birth evolved from a physiological event into a medical procedure. According to one of the foremost authorities of the day, Dr. Joseph DeLee, birth was a dangerous process from which few women escaped unscathed, and proper management of this pathological condition required a program of routine medical intervention. DeLee's recommended interventions included anesthesia, episiotomy, and assisted (forceps) delivery. By the 1960s, these interventions were common in all American hospitals and women were unaware of any other way to give birth (as well as unaware when they were giving birth!). In addition, women were forced to labor without presence or support from partners or family, infants were taken from the mother at delivery and cared for in newborn nurseries, bottlefeeding became the norm, and babies born outside the sterile environment of the operating room were labeled contaminated and kept separately. There was no scientific rationale for any of these procedures; to the contrary, many of them were eventually shown to be harmful. Midwifery, meanwhile, was declared to be illegal in most jurisdictions, and as the old "granny" midwives died out, the profession almost died with them. Midwifery never succumbed completely to the campaign waged against its 4
practitioners by the medical profession. Granny midwives in the rural south continued to serve poor, mostly black women. Motherwit is the story of one such midwife, Onne Lee Logan, who was born in 1910 in Sweet Water, Alabama, the fourteenth of sixteen children and the daughter of a midwife. She learned her midwifery by accompanying her mother to births. Eventually she became the most widely respected and sought after midwife in the region; in the book, she share her stories, secrets, faith, and wisdom. Listen to Me Good: The Life Story of an Alabama Midwife is the story of another Alabama midwife, Margaret Charles Smith.{mospagebreak} IV. Modern Nurse-Midwifery During its darkest times, the seeds of the future of midwifery were being sowed. Although slow to grow, they proved to be enduring. On one front, public health nurses with the Frontier Nursing Service in the mountains of Kentucky and the Maternity Center Association in the medically underserved neighborhoods of New York City in the 1920s acquired additional training in midwifery to provide maternity services to women who were being ignored by the physicians and receiving inadequate maternity care. They called themselves nursemidwives. (To learn more about the history of the Frontier Nursing Service, read Wide Neighborhoods, the autobiography of its founder, Mary Breckenridge. Mary Breckenridge introduced modern nurse-midwifery, based on the British model, into the United States. In 1925 she established the FNS as a demonstration project of complete family health care in a remote rural area, and directed it until her death in 1965.) By the 1950s, nurse-midwives were well established in several medical institutions, and nurse-midwifery education was moving into institutions of higher learning and becoming standardized. In 1955, a small group of nurse-midwives founded the American College of Nurse-Midwifery, which merged with the American Association of Nurse-Midwives in 1968 to become the American College of Nurse-Midwives (ACNM). Although home birth had been the norm in the early days, nurse-midwives gradually moved almost completely into hospital settings, usually relinquishing control and autonomy over their practice to physicians and adopting some of the interventive procedures used by them. The trade-offs for these losses included a legal sanction to practice, assurance of appropriate physician consultation when needed, and a living wage. More recently, most nurse-midwives have been able to obtain prescriptive privileges, hospitaladmitting privileges, and the right to third-party reimbursement (insurance payment). Nurse-midwifery practice grew rapidly in the 1980s and 1990s, with nurse-midwives assuming a large part of the care of underserved and vulnerable women from isolated rural and impoverished inner-city areas. Many of these women bring with them significant psychosocial problems that put them at an increased risk for poor obstetric outcomes. Nonetheless, data showed from the beginning, and continue to show, that these women experience superior outcomes with nurse-midwifery care.{mospagebreak} V. The Rebirth of Home Birth On a second front, in the late 1950s, consumers of hospital-based, medicalized maternity care began to rebel. There was a growing interest in childbirth education, breastfeeding, and natural childbirth. Women and families who were pessimistic about their chances of having a safe and satisfying birth in the hospital began to explore the option of home births with midwives. The midwives who attended these births were unlikely to be professionally educated as midwives; their interest in midwifery was frequently though personal birth experiences; their training was by apprenticeship, and their practice was by and large unregulated, either illegal or not mentioned in the law. Initially, they were not organized, but worked in isolation in diverse parts of the country. Gradually, the phenomenon attracted the attention of state regulatory authorities and the medical profession, who began to clamp down on "lay" midwives, in some cases arresting or prosecuting them for practicing medicine without a license. Despite restrictions, a small but steady number of families continued to demand alternative childbirth, and the midwives attending them began to organize to share experiences, support one another, and learn together. During the 1970s, the proportion of out-of-hospital births almost doubled, although the overall number was small. In 1975, the publication of Ina May Gaskin's book, "Spiritual Midwifery," spread the word that childbirth could be an experience of growth, empowerment, and joy. For an interesting recent online article on Ina May, seehttp://www.salon.com/people/bc/1999/06/01/gaskin/ . In 1982, the Midwives' Alliance of North America (MANA) was founded. The organization embraces all midwives, regardless of training or credentials; however, its focus became the expansion of practice rights for direct-entry midwives who attended home births. The midwives represented by MANA have steadfastly insisted on autonomy and control over their practice, and differentiation of the midwifery model of care from the medical model. This freedom to practice without outside control has not been without costs; 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.{mospagebreak} VI. Current Trends and the Future of Midwifery During the 1990s, differences between the two groups of midwives became less distinct. Through MANA, direct-entry midwives developed standards for accreditation of educational pathways and for certification of midwives; they formed separate organizations to perform these functions.They worked for legalization of midwifery practice at the federal and state level, and for improved interaction with the health-care system. Meanwhile, ACNM began to accredit direct-entry midwifery educational programs and to work for increased autonomy of nursemidwives through legislative and regulatory changes. Most importantly, scientific validation for the midwifery model of care began to emerge in the literature, much of it contained in a massive review of 7000 clinical research studies known as "Effective Care in Pregnancy and Childbirth," or familiarly as the Cochrane database. This systematic review of the scientific evidence classified the elements of care during pregnancy and childbirth as effective, promising, not proven either way, or not worth using. Many of the elements of the midwifery model of care were validated by this ongoing review, which became the midwives' bible. At the present time, there is no doubt that midwives offer women safe, effective care with good outcomes; now midwives ourselves are looking at our practice to see just what we do that makes this so. We believe that the answer lies in our name; that is, we are "with women." We listen to women, we talk with women, we stay with women. Every year, more American babies are born into the hands of midwives. The national average is 7.4%, although in some states it is as high as 20%. Still, the rate is very low compared to that in the European countries with the best birth outcomes. Midwives believe that our care can enhance the experience of pregnancy and birth for women. Hopefully, this website will inform women about midwives and encourage midwives to come together and to learn from one another.
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