Since no written record exists, we can only speculate what a birthing woman in prehistoric times would have experienced. Certainly she had noticed the changes in her own body, and movement in her womb. Probably she had realized that this change and movement was the same change and movement that came before the labor pains that had brought babies out of her mother, sisters or aunts. It is likely that, as her labor pains started, at least one of those mothers, sisters, or aunts who had already experienced childbirth was compelled to comfort her and to teach her what they had learned through their own births and the births of other women. They may have helped her get into a favorable position for pushing, stimulated her baby, or instructed her to bring the baby to her breast. They almost certainly comforted her through her labor. Those mothers, sisters, and aunts were the first midwives.
The first records of midwives come early in written history. An ancient Egyptian painting depicts the goddess Ritho giving birth to the god Ra with the help of four midwives (Arab). The bible speaks, several times, of midwives. Starting in the 35th verse of Genesis, the bible tells how a midwife comforted a woman during a very hard labor. The bible goes on to tell us, in the first chapter of Exodus, about two of the most famous midwives of all – Shiphrah and Puah – who refused to kill baby boys even though they had been ordered to by the pharaoh. We know from ancient writings that a woman giving birth in Athens or Greece would have been attended by a midwife who was required to have already borne children, and that the midwife would have been paid for her services (Sellers, 1993). During this very early time period, knowledge was gained by observation of natural birth. Women learned though their own childbirth experiences and though the experiences and stories of others (Burtch, 1994).
The first notes of competition between male and female caregivers began to show themselves in the early middle ages, starting a political battle that still rages today
(Wainwright, 2006). The tradition of woman attended, naturally guided childbirth started to change around the third century BCE, when men started to produce texts to aid midwives in their work (Schaus, 2006). These texts contained much speculation since their male writers had little firsthand knowledge of anatomy, or childbirth. Contributors included such famous names as Hippocrates and Aristotle (Sellers, 1993). One of the most enduring texts was written by a Roman Doctor, Soranus, who is believed to be the first doctor to specialize in obstetrics. His book, De Morbis Mulierum, became a primary source book for midwifery for the next 1500 years (Radcliffe, 1989). Soranus listed requirements for the art of midwifery that are still relevant today, such as having rounded nails so as not to injure patients, having a love for the work, and having a lot of experience before taking on clients. Another Roman, Galen, also wrote medical texts concerning the technical aspects of childbirth. He was not overly scientific and was responsible for many erroneous theories. He did, however, described how a midwife would check for cervical dilation and describes the use of a birth chair, affording us a glance into the advancing science of childbirth. Later, a woman physician named Trotula, who was trained at a famous medical school, further wrote about midwifery skills including how to remove retained placenta, and how to repair perineal tears. Many other physicians and scientists of this period endeavored to advance human understanding of birth, and recorded their ideas. Some ideas gave rise to better treatment of complications, and some ideas undoubtedly caused complications that would have otherwise been absent (Sellers, 1993).
Until Christianity, the struggle for dominance over birth was a tense, but somewhat polite debate. Early doctors had little or no interest in normal pregnancy, and were usually called only when a disease or complication arose (Rooks, 1997) Early women struggled to gain knowledge of the medical arts, but there were, at least, some women who did gain the information and write about it (Sellers, 1993). During the 15th and 16thcenturies, however, midwives came to be supervised by the church, and they were forced to participate in religious rituals that could be harmful, or even deadly to mother and child (Rooks, 1997).
Midwifery undoubtedly existed in some form for Native Americans, but most of the accounts we have about native childbirth customs are from European settlers, which makes them somewhat questionable. Several of these accounts tell of Native women who wandered into the woods, alone, to give birth but we must wonder if this was the truth, or was a result of the native women wanting to protect their privacy (Pearson). In contrast, modern American midwifery sprouted directly from its European counterpart. The first European midwife came to America on the Mayflower, probably delivering three babies on the way over. This midwife, Bridget Lee Fuller, then settled in Plymouth and was known, and supported, as the “town midwife” (Rooks, 1997, p. 18). During colonial times, skilled midwives were much-sought-after members of communities, and were well taken care of by the communities they served. The vast majority of births in early America were attended by these traditional midwives (Mintz, 2007).
Martha Ballard may be the most well known of these midwives. Her careful diary allows a glimpse into the politics and science of midwifery near the turn of the 19th century. From her diary we know that midwives attended not only to births, but also to many medical needs in their communities. Martha, specifically, worked in unison with the doctors who served the same population (Ulrich, 1990). It is probable that many early American midwives enjoyed this collaboration of medicine and midwifery. A physician even opened a school for midwives, male and female, in 1765, but since most midwives were unable to read, he soon restricted his class to men only (Rooks, 1997). Male doctors began attending more women, during this time, mostly to serve their own academic and financial interests (Frye, 1995). Despite a growing tendency for wealthy, urban women to have physician attended childbirth (so that they could receive pain relief and access to forceps), American birth in the late colonial era remained a woman-centered event. Even though, or perhaps because, roughly one-fifth of women perished in childbirth, a birth was seen as a communal celebration. Women would gather to support the laboring woman, and midwives were important members of the community (Collins, 2003; Rooks, 1997).
Another early American midwife was the black, slave-midwife who was carried over on slave ships and cared for black and white women, both. These midwives were prized, in the south, and sometimes were even hired out to other plantations (Covey, 2007). These “grannies” became the “granny midwife” of the south (Frye, 1995).
The turn of the 19th century brought the industrial revolution, and with it, sweeping changes in childbirth. Many Americans had moved into the cities to work at the factories, causing a boom in the urban population. Surprisingly, the number of doctors was increasing at a rate four times that of the general population, and they faced stiff competition to start a successful practice. These new doctors knew that obstetrics was an excellent way to win the position of “family” doctor, so they launched an aggressive campaign to win over birthing mothers (Frye, 1995; Collins, 2003). Their success was dramatic in urban areas. In Philadelphia they were so successful that the number of midwives dropped from twenty- one to only six in the short span from 1815 to 1821. During this time, doctors attended births at home, but they eradicated the supportive atmosphere of women-in-fellowship by requiring that everyone else leave the room. (Collins, 2003)
The early 20th century saw the most dramatic changes in midwifery yet. In the early 1900s, when 50% of births were still attended by midwives, the American maternal and infant mortality rate was dramatically higher than many other industrialized nations. This fact was used as ammunition against traditional midwives by doctors, who were trying to take over the business of obstetrics, and by public health nurses, who were establish a nursing specialty in midwifery. These doctors and nurses launched an overtly racist smear campaign designed to drive the traditional midwife out of business, and drive her clients into the hands of curious, untrained doctors. Midwives were attacked on every front. Personally, they were accused of being crude, dirty, and of questionable morals. Professionally, they were maligned as untrained (despite the fact that a self-survey of the obstetric specialists of the time revealed them to be woefully uneducated). Midwives were marginalized by new rules about who could or could not practice medicine, and studies which indicated that a woman was safer with a traditional midwife than with other providers were blatantly ignored (Dawley, 2003).
This smear campaign, which unfolded between 1910 and 1930, was primarily carried out because midwives were seen as a hindrance to medical education, since they were attending births that could otherwise be observed by medical students and practicing physicians. Midwives were also viewed as an embarrassment to the practice of obstetrics, because if some uneducated grannies could do it, obstetrics was a much less prestigious as a specialty. Most doctors knew that women did better in the hands of midwives, but that fact was inconvenient to their selfish motives, so they went ahead with their “witch hunt” (Wagner, 2006).
Higher class woman bolstered the efforts of the doctors by insisting that they should receive anesthesia during childbirth. Since these upper class women were willing to give birth in the hospital in order to get pharmaceutical pain relief, and even started “twilight sleep” societies, they helped to push medicalized birth into the realm of “trendy”. Consequently, the growing middle class began to idealize hospital birth as a mark of success, and even poor women started to visit the “maternity wards” that had been made available to them (Rooks, 1997).
By 1932 the number of births attended by midwives had dropped to 12.5%. In a happy, but ultimately damming, coincidence the maternal death rate also fell sharply over this period. At the time, the drop was attributed to more births taking place in hospitals with physicians in attendance, but in retrospect appears to be due to advancements in other areas of medicine, including the invention of antibiotics and blood transfusions (Rooks, 1997, p. 30). The remaining midwives were mostly traditional birth attendants from the south, serving populations that were underserved by the medical establishment. Sadly, even those populations were soon targeted by a new breed of midwife, the nurse-midwife (Wagner, 2006).
In 1925, a public health nurse named Mary Breckinridge established the first nurse-midwifery service in the United States, Frontier Nursing Service. She had come with British training, and helped to launch a new profession that was a hybrid of nursing and midwifery. This new profession was autonomous, but was unfortunately saddled with the stigmas of both sides. The medical profession associated the new nurse-midwife with the traditional midwives that they had spent so much time defaming, and also saw them as a threat to their growing dominance in the birth field. The traditional midwives associated them with the subservient nurses of medical practice and viewed them with contempt and mistrust. In turn, the FNS nurse-midwives denounced the work of the traditional midwives, driving them further underground. In 1939 FNS launched a graduate school which still trains nurse-midwives today as the Frontier School of Midwifery. Nurse-Midwives have made considerable advances as autonomous medical professionals, with many having homebirth or hospital practices today (Ettinger, 2006).
Traditional midwifery was effectively driven underground during the next twenty years, and nurse-midwifery was mostly confined to the poorest areas. Hospital birth was nearly universal, and medicine continued to come up with new, and sometimes dangerous, interventions. Then, in the 1960s a backlash against the medical interference in birth began to take shape. Nurse-midwives enjoyed a rapid expansion and their practice was legalized in almost every state. Traditional midwifery also experienced resurgence during this time period. The the percentage of homebirths doubled during the 1970’s, largely due to a spike in planned homebirth, and the whole history of traditional midwifery basically re-created itself in the United States, with women learning whatever they could from medical texts, other women, and their own experiences. In 1975 a self-taught midwife named Ina Mae Gaskin published a book called “Spiritual Midwifery” which was a sort of manual for other lay midwives based on her own, personal experiences. With this publication she secured her position as one of the founders of the renaissance of traditional midwifery (Rooks, 1997).
Current State of Direct Entry Midwifery
In 1983 the Midwives Alliance of North America (MANA) started working on a concept of a national skills test and registry of direct entry midwives. Working together, DEMs and CNMs came to realize that DEMs needed to develop their own credential, and in 1992 a new organization was formed with this goal. That organization, the North American Registry of Midwives (NARM) now grants a credential called the Certified Professional Midwife (CPM) that is a legally recognized credential by not less than 23 states. Today, in 2011, there is a nation-wide push to bring this certification into national recognition (History of the development of the CPM).
I have undoubtedly left out important instances in the history of midwifery. I know I left out significant happenings, because the central truth to midwifery is that almost every moment is significant. Every birth is worthy of recording. Gratefully, the history will keep writing itself, and midwifery will continue to grow, and flourish, no matter what attacks or hardships it must overcome. It will continue as long as there is one woman who reaches out to another woman to comfort her during the trial of childbirth because the history of midwifery is the history of women.
Arab, S. M. (n.d.). Medicine in ancient Egypt. Retrieved July 25, 2011, from Arab World Books: http://www.arabworldbooks.com/articles8b.htm
Burtch, B. (1994). Trials of labour : The re-emergence of midwifery. Montreal, QC, CAN: McGill-Queen’s University Press.
Collins, G. (2003). America’s women: Four hundred years of dolls, drudges, helpmates, and heroines. New York, NY: Harper Colins.
Covey, H. C. (2007). African American slave medicine: Herbal and non-herbal treatments. Lanham, MD: Lexington Books.
Dawley, K. C. (2003). Nurse-midwifery in the United States and its 1940s expansion: Early twentieth century origins: Frontier Nursing Service and Maternity Center Association. Journal of Midwifery & Women’s Health .
Ettinger, L. E. (2006). Nurse-midwifery: the birth of a new American profession. Ohio State University.
Frye, A. (1995). Holistic midwifery Vol I. Portland, OR: Labrys Press.
History of the development of the CPM. (n.d.). Retrieved October 17, 2011, from North American Registry of Midwives: http://narm.org/certification/history-of-the-development-of-the-cpm/
Mintz, S. (2007). Childbirth in early America. Retrieved July 26, 2011, from Digital History: http://www.digitalhistory.uh.edu/historyonline/childbirth.cfm
Pearson, E. H. (n.d.). Native American customs of childbirth. Retrieved 9 19, 2011, from Teaching History . org: http://teachinghistory.org/history-content/ask-a-historian/24097
Radcliffe, W. (1989). Milestones in midwifery ; and, The secret instrument (The birth of the midwifery forceps). Norman Publishing.Rooks, J. (1997).Midwifery and childbirth in America. Philladelphia, PA USA: Temple University Press.
Schaus, M. (2006). Women and gender in medieval Europe. CRC Press.
Sellers, P. M. (1993). Midwifery, Volume 2. Juta and Company Ltd.
Ulrich, L. T. (1990). A midwife’s tale. New York: Random House.
Wagner, M. (2006). Born in the USA: How a broken maternity system must be fixed. Berkley, CA: University of California Press.
Wainwright, E. M. (2006). Women healing/Healing women : The genderization of healing in early Christianity. London, GBR: Equinox Publishing Ltd.
copyright Sarah Foster 2012