A BRIEF HISTORY OF MIDWIFERY

By Cordelia S. Hanna-Cheruiyot, MPH, CHES, CCE, CBA

 ”A Midwife should have a hawk’s eye, a lady’s hand, a lions heart”

-From a 16th Century Midwifery Text

A Brief History of Midwifery 

Carrying the knowledge of birth and death, women’s sexuality, healing methods and medicinal plants,  since the dawn of time to the present, across all cultures, midwives have attended the majority of the world’s women during childbirth. One of the world’s oldest professions for women is midwifery. 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,  ministries of health in the lesser developed regions of the world  do the same with  training Traditional Birth Attendants ). Grannies are almost extinct today, however The International Center for Traditional Childbearing mission is  to cultivate indigenous midwives and doulas  of  African-American heritage to address the alarming  disparities in African-American infant and maternal mortality.

Starting in the  1970s,  “lay midwives,”  began to enter the birth scene. They were women who attended births but were not trained through a formalized academic course of instruction, though they often trained through apprenticeship,   and were not licensed or certified,   further confusing  the definition of a midwife in America.  The World Health Organization uses the term “Traditional Birth Attendant” (TBA) to describe the women who are not formally trained but who care for pregnant women and help them give birth. “The term TBA is rarely used in the United States”, says Judith Rooks.  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

Forceps Delivery

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. The nurses fed  them artificial baby milk (so-called “formula”), as women were discouraged from breastfeeding, and were given drugs to make their milk dry up.

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 Mdiwives.

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 outcomes. 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

About the Author

Cordelia Hanna-Cheruiyot, MPH, CHES, CCE, CBA, has been a midwifery activist and student of midwifery and childbirth for two  decades. She

©Shawna Wentz Photography Sacred Womb Artistry

has attended births in hospitals, birth centers and homes since 1991. She 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 breastfeeding counselor educator and has taught childbirth preparation classes to hundreds of parents for two decades.  She trains aspiring midwives, doulas and breastfeeding peer counselors. She has a Masters in Public Health in Health Education and Promotion/Maternal Child Health from Loma Linda University and a Certified Childbirth Educator and Certified Birth Assistant. 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.