The History 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 is born in this world is born into the hands of a midwife.
Native Americans had midwives within their various tribes. Midwifery in Colonial America began as an extension of European practices. It was noted that Brigit Lee Fuller attended three births on the Mayflower.
Midwives filled a clear, important role in the colonies, one that Laurel Thatcher Ulrich explored in her Pulitzer Prize winning book: A Midwife's Tale: The Life of Martha Ballard based on Her Diary 1785-1812.
Midwifery was seen as a respectable profession, even warranting priority on ferry boats to the Colony of Massachusetts. Well skilled practitioners were actively sought by women. However, the apprentice model of training still predominated. A few private tutoring courses such as those offered by Dr. William Shippman, Jr. of Philadelphia existed, but were rare.
The scientific nature of the nineteenth century education enabled an expansive knowledge explosion to occur in medical schools. The formalized medical communities and universities not only facilitated scientific inquiry, but also communicated new information on a variety of subjects including Pasteur's theory of infectious diseases, Holmes' and Semmelweis' work on puerperal fever, and Lister's writings on antisepsis.
Since midwifery practice generally remained on an informal level, knowledge of this sophistication was not disseminated within the midwifery profession. Indeed, medical advances in pharmacology, hygiene and other practices were implemented routinely in obstetrics, without integration into midwifery practices.
The homeopathic remedies and traditions practiced by generations of midwives began to appear in stark contrast to more "modern" remedies suggested by physicians.
Obstetricians began to identify a difference not only in the practices of the two professionals, but also in the neonatal/maternal outcomes between births attended by physicians and those by midwives.
Statistics regarding maternal deaths and neonatal deaths which were available, demonstrated that midwifery attended births often (although not in all studies) had poorer statistical outcomes than physician attended deliveries. It must be noted that this discrepancy may have been influenced by other factors. For example, as physicians became the provider of choice for the affluent woman, midwives cared for an increasing number of poor women.
These midwifery clients usually lived either in rural areas of the country, or in immigrant areas of large urban cities where poor nutrition and poor sanitation were the norm. The discrepancy between care of the two groups of providers was not as apparent in Europe, for it was during the 19th century that formalization of midwifery education had occurred in that continent, and statistical outcomes of midwifery practices were comparable to that of physicians in the same countries.
Regardless of etiology, the difference between statistical outcomes of midwives and physicians in the United States precipitated a situation in health care characterized as the "midwifery problem".
The midwifery controversy lasted from approximately the end of the 19th century through the first two decades of the following century. Although the concern about neonatal and maternal outcomes has been named as the major causative agent for the controversy, other historians have also suggested alternative factors. Kobrin suggested economic impact as another central issue.
The early twentieth century was a period of intense immigration. Most immigrant groups brought their own midwives with them who were familiar with the pregnant woman's culture, beliefs, diet and needs. Another sociological factor which had an influence upon the health care of women was World War I (1914-1918). As the United States became involved in the conflict overseas, individuals became members of the armed services and the abundance of domestic help decreased. Women began to seek alternatives for support after delivery.
They discovered the care given in the hospital for childbirth included food and housing. However, hospitals were not owned by midwives, nor were midwives allowed to conduct births in hospitals.
Two major solutions were posed to the midwifery problem. One solution was to educate midwives in order to raise the level of practice to the accepted mainstream. European midwifery practice was used as an example. The second proposed solution of the midwifery problem was to abolish midwives for the sake of the health of the country. Midwifery of untold centuries was almost eradicated in the United States in less than three decades by restrictive legislation and an effective public campaigns.
Midwifery did not totally vanish from the United States. It became practiced in only a few areas by less and less midwives. The few midwifery schools that had been established closed, as the need was no longer apparent. The practice of midwifery became exclusively associated with care of the foreign born or the nonwhite. In 1915 40% of all births were attended by midwives. However, by 1935, that number had decreased to 10.7%, of whom 54% were nonwhite.
Even as traditional midwifery began its marked decrease in popularity, a new type of midwifery was developing in the United States. Mary Breckinridge, a woman from a prominent American family who had experienced personal childbearing losses, sought to find a worthwhile project through which she could promote maternal and child health.
A dilettante in her younger years, Breckinridge found herself in the 1920s a victim of an unhappy marriage and the loss of two young children. She discovered similarities between herself and other women from her home state of Kentucky.
Armed with her formidable social and political connections (her grandfather had been Vice President of the United States, and her father had been an Ambassador) and possessing an inquisitive mind, she sought alternative practices to the prevailing models of care. After traveling abroad, she surmised that the British model of the nurse-midwife offered the most promise.
Mary Breckinridge was so committed to the concept of nurse-midwifery that she herself attended nurses' "training" and was then educated as a midwife in Britain. Accompanied by venturous British nurse-midwives, she returned to the United States and formally founded the Frontier Nursing Service (FNS) in Hyden Kentucky in 1925.
Mary Breckinridge evidenced foresight in her belief in the system of nurse-midwifery. She felt nurse-midwives would make impact on the outcome of a pregnancy. In her autobiography, she recounted plans of not only developing a strong clinical program, but also her desire for FNS to be a prototype of a service that could be replicated elsewhere.
To that end, she developed a strong thread of ongoing statistical accrual in FNS. Furthermore, she advocated development of an educational program for the future. Nurse-midwives of the Frontier Nursing Service integrated the support of the parturient with case finding inherent in public health nursing.
Routine home visits were done with an emphasis on hygiene and health education. As Breckinridge noted, compliance of patients with prenatal care increased particularly as care became accessible through local district offices or through home care. It was through such care that the Frontier Nursing Service has consistently demonstrated lower perinatal and maternal mortality statistics when compared to either state statistics or national statistics.
These statistical outcomes were particularly impressive when viewed in light of the socioeconomic status of the Appalachian clientele. Even today Mary Breckinridge's vision continues.
FNS now is home to a Community Based Nurse-Midwifery Education Program, a distance learning program that is particularly targeted for nurses who wish to stay in their communities and study nurse-midwifery. It combines formal study, modern technology with aspects of apprenticeship as students work closely with CNMs in their area, even though their formal program may be housed a thousand miles away.
In the 1930s another group had intentions similar to those of Mary Breckinridge. Again, the nurse-midwifery model was suggested to care for another population of women who were medically underserved and who frequently suffered loss of children.
Independent of the Frontier Nursing Service, the Lobenstine Clinic initiated a program in 1931 to educate nurse-midwives to care for disadvantaged women in New York City, the country's most populous city. This education program survives today, although it has undergone some evolution and change over the years. Today it can be traced to the State University of New York Downstate Nurse-Midwifery Program.
Thus, two small nurse-midwifery programs began in the 1930s. Traditional midwives continued to practice, however they did so at a steadily decreasing rate. Today there are more than 40 programs in the United States.
Professional organizations for nurse-midwives first began with the establishment of the American Association of Nurse-Midwives by Frontier Nursing Service in 1928. Due to location, it was generally composed of nurse-midwives employed by FNS. The National Organization for Public Health Nursing (NOPHN) offered a larger forum and political base when a subsection for nurse-midwives was founded.
This was short lived, for in 1952 seven nursing organizations including NOPHN, were recombined and became integrated into the American Nurses Association and the National League for Nursing.
Neither of these groups had provisions for a subgroup of nurse-midwives. The decision was made to establish a new organization and the American College of Nurse-Midwifery was chartered in 1955. In 1968, this organization combined with the American Association of Nurse-Midwives to form the American College of Nurse-Midwives.
During the early years of nurse-midwifery, the opportunities for clinical practice were limited. Prior to the 1960s nurse-midwives often functioned as supervisors and consultants to indigenous midwives in the Southern United States.
Yet nurse-midwifery grew slowly. The basic commonality in early years was one of clientele. As Tom described, "Nurse-Midwives' work demonstrate that midwifery in this country has its roots in poverty, both rural and urban and in home deliveries".
However, nurse-midwifery began to grow more rapidly during the 1970-1980's. Among the major historical events which facilitated the increase acceptance of nurse-midwifery were the safety and satisfaction of the care provided. Several studies provided insight.
Montgomery (1969) and Levy, Wilkinson and Marine (1971) reported on a California project in which nurse-midwives were introduced to a rural, medically underserved area. In the first eighteen months of the project, prematurity rates decreased from 11% to 6.6%. The neonatal death rate dropped from 23.9% to 10.3%.
Other decreases were apparent in fetal and infant death rates. The causative significance of nurse-midwifery in the California project was strengthened when, at the end of the project's funding, the nurse-midwives left and were replaced by physicians.
During the next two years, the prematurity rate rose from 6.6% to 9.8% (statistically significant at a p<0.02 level) and the neonatal mortality rate increased from 10.3% to 12.!% (statistically significant at a p<0.005 level).
Alternative explanations of social/economic/medical changes were offered and explored, but were inadequate to explain the changes in statistics. The only plausible explanation by the authors was the introduction and removal nurse-midwifery care.
Slome et.al. compared care given by nurse-midwives to that given by resident physicians in clinics and found no significant differences in major outcome criteria. One difference which was demonstrated concerned increased patient compliance as evidenced by the fact that nurse-midwifery clients kept 95% of scheduled appointments as compared to 80% kept by physician clients.
Recent reports by the US Institute of Medicine and the National Commission to Prevent Infant Morality has shown a lower incidence of low-birthweight babies delivered by Nurse-Midwives.
In November of 1995, the Public Citizen's Health Research Group reported that women cared for by nurse-midwives (who were of low risk as well as some moderate and high risk status based on practice site) were half as likely to have a Cesarean section for birth.
Consumers first became acquainted with nurse-midwifery as articles on the rebirth of the midwife appeared in popular magazines such as Time and Life in the 1970s. The consumer became interested in nurse-midwifery for several reasons.
Nurse-midwives became familiar to many consumers through their participation in the development of the first alternative birth centers. Consumers also encouraged new types of practices. Nurse-Midwives began to care for an increasing number of women from all socioeconomic sectors.
Nurse-midwives strengthened ties with the public in several ways. They provided national standards of practice. They developed a certifying examination to provide a measure of quality assurance for entry into practice and protection of the public. Only upon successful completion of the national examination, can an individual call him or herself a "Certified Nurse-Midwife" or CNM.
Consumers who valued health care cost containment were also intrigued by certified nurse-midwives. Certified Nurse-Midwives have been proposed as potential cost saving providers due to a lower salary, use of limited, rather than routine use of selected artificial technology, a decrease in Cesarean birth rates and the emphasis on health promotion and health maintenance.
Today there are more than 5,000 Certified Nurse-Midwives in the United States who attend approximately 150,000 births annually, primarily in hospitals. They work in a variety of practices, including group practices with physicians, HMOs, rural and urban areas among private and public clients. All nurse-midwives have a relationship with an obstetrician in case of complication.
Parkland School of Nurse Midwifery
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