History of Midwifery 1
Thriving or Surviving: A History of Midwifery Worldwide
Ashley Musil
Module I, Introduction to Midwifery
November 4, 2011
Abstract
One of the oldest professions in the world, midwifery is mentioned in numerous ancient texts. The profession of midwifery has faced many challenges over the course of history. Education, regulation, and public opinion have all forged midwifery into a uniquely diverse profession worldwide. Various countries have seen midwifery become a pillar in society or an outlawed practice forced underground by persecution. From respect and esteem to witch hunts and smear campaigns, midwives have survived the ever changing face of society. In the United States, the face of midwifery resembles a tree with many branches representing each educational path and practice philosophy. However, midwives as a whole still only account for six percent of U.S. births, a statistic that is likely to change over time if history repeats itself.
Thriving or Surviving: A History of Midwifery Worldwide
From the beginning of human existence, women have helped each other give birth. One particularly skilled in, or called to, this task emerged as the midwife, a term derived from Middle English: mid, meaning “with” and Old English: wif, meaning “woman” (Midwifery, n.d.). This term was used as early as 1303; however, midwifery in the sense of “women helping women give birth” has existed throughout the history of mankind (Rooks, 1997, p. 3). Although this profession has existed from the earliest recorded times, it has faced opposition in almost all parts of the world at some point in history.
One of the earliest written references to midwives is recorded in the Old Testament of the Bible. Exodus, Chapter 1, describes how the Hebrew people were enslaved in Egypt and multiplied greatly. The Egyptian Pharaoh feared their potential power and commanded the Hebrew midwives to kill all male babies born to Hebrew women. The midwives, however, feared God and allowed the male babies to live. When Pharaoh asked them why they disobeyed his orders, the midwives replied that the Hebrew women had easier labors than the Egyptian women and would deliver their babies before the midwife arrived. “So God was kind to the midwives and the people increased” (Exodus 1:20New International Version).
Midwifery in Greco-Roman antiquity included old women, trained midwives, and highly trained women who were considered female physicians. The various titles assigned to midwives ranged from nurse or midwife in Greek to obstetrician or doctor in Latin. The actual duties of ancient midwives consisted mainly of assisting with births, although they may have also helped with women’s other medical problems. In ancient Egypt, midwifery was recognized as a female occupation, according to the Ebers papyrus which dates from 1900 to 1550 BCE (Midwifery, n.d.).
Midwifery training has long been a tug-of-war between formal and informal education. Early midwives were primarily trained through apprenticeship, often with an older female relative. The first documented formal midwifery training program was started by Hippocrates in the fifth century BCE. Two hundred years later, an Athenian midwife disguised herself as a man to complete a course in an Egyptian medical school. The school was run by Hierophilus, who wrote what is thought to be the first book on anatomy for midwives. During the thirteenth century, women could study nursing and midwifery at a school in Solerno, Italy (Rooks, 1997, p. 12). Education of midwives has not been the only trial facing midwifery.
The 1487 publication of Thewitchhammer by two Dominican inquisitors started a hunt for witches. “If a baby died, the midwife who attended its birth might be accused of having offered the baby to the devil” (Rooks, 1997, p. 13). In addition, midwives used herbs, potions, and spells to assist laboring women. These practices seemed witchlike to some priests, and midwives were accused of being witches. Between 1450 and the mid-1700s, about sixty thousand people were executed, often burned at the stake, as “witches;” approximately 80 percent of them were women, more than half of whom were midwives (Rooks, 1997).
Regulation of midwives throughout history has been another subject of great controversy and ever-changing policy. Parisian midwives came under regulation to some extent during the late 1300s, but only those looking for wealthy clients applied for certification (Rooks, 1997, p. 13). The first law to regulate European midwives was enacted in Regensburg, Germany in 1492. The groundbreaking law defined midwifery as a profession and ensured midwives equal rights with other professional craftsmen. The first regulatory statute for licensure in Paris was passed in 1560. Certified midwives agreed to report practices by uncertified midwives and to call a more experienced midwife or physician when faced with difficult cases (Rooks, 1997, p. 12). By the mid-1600s, Paris emerged as the center for childbirth, partly due to the effort of a literate French midwife, Louyse Bourgeois.
Bourgeois (1563-1636) developed a high reputation among Parisian aristocracy. Not only was she a middle-class, literate midwife, but she was also married to a physician, and later became midwife to the Queen of France, delivering all six heirs of King Henry IV. She was the first midwife to write and publish books, developing the still-used technique of dealing with a tight nuchal cord by tying it in two places then cutting between the ligatures. She resembled a modern-day midwife in that she advocated a patient, non-intervening approach to childbirth. Bourgeois also argued against physicians’ manipulations, recognized the importance of the mother’s emotional state, and urged midwives to provide support, encouragement, and comfortable positions for women during labor. She believed in treating each pregnancy as a unique and individual experience and respected the power and mystery of birth (Rooks, 1997, p. 14). Bourgeois’ writings were influential throughout Europe, sprouting official midwifery programs in Leiden in 1725, Edinburgh in 1739, Vienna in 1748, and Strasbourg in 1751. By the twentieth century, all European countries except England had developed educational standards for midwives and government-supported midwifery schools (Rooks, 1997).
Midwifery around the world has undergone many transformations throughout history, but through it all the profession has survived and even thrived in some parts of the world. In the United Kingdom, modern midwives are the lead health care professional attending the majority of births, mostly in a hospital setting, although home birth is also an option for many births. Midwifery in Canada was reintroduced as a regulated profession in the 1990s.Fully integrated, regulated and publicly funded midwifery is now part of the health system in seven provinces, the Northwest Territories, and Nunavut. In New Zealand, midwifery gained status as an autonomous profession in 1990, and about 78 percent of women now choose to give birth with a midwife. In the Netherlands, home birth is still a common practice. Between 2005 and 2008, 29 percent of babies were born at home rather than in a hospital. In Japan, midwifery was first regulated in 1868, and modern midwives must pass a national certification exam. In Balochistan (tribal Pakistan), midwives are the third most powerful leaders in the community (Midwifery, n.d.), similar to the early history of the United States.
During the first 250 years of colonial life in the United States, midwives were responsible for the care of almost all pregnant women. There were few university-educated physicians, so midwives were often the sole source of healthcare. They were highly respected members of their communities. As the population expanded, most early American midwives practiced in isolation without any form of regulation. They did not perceive themselves as members of a profession and passed their knowledge and skills through apprenticeship (Rooks, 1997). This disorganization left the profession of midwifery vulnerable to moral attack.
The first formal instruction of American midwives was offered in 1765 by Dr. William Shippen, Jr., a Philidelphia physician who offered the educational opportunity to both men and women. However, few midwives were literate and many could not afford to attend school, so Shippen soon limited his course to men. By the end of the eighteenth century, four male-only medical schools had been established in the United States. Then, in 1848, Samuel Gregory, a non-physician graduate of Yale, established the Boston Female Medical College. He was motivated by moral outrage over the growing involvement of men in the physical care of women. The school was harshly criticized by the Boston Medical Society, and it closed in 1874 (Rooks, 1997).
By the mid-1800s, there were tens of thousands of midwives in the United States, but the need for formal training, both for midwifery and obstetrics, far outweighed the availability. Most midwives and doctors prepared themselves through apprenticeships and self-study. As throughout history, some women continued to assist the deliveries of family and friends with little training at all. Laws governing the practice of midwifery in the United States were local and varied widely. Midwifery was still completely unregulated in twenty states in 1900. By then, physicians were attending about half of the nation’s births, including nearly all births to middle- and upper-class women. Midwives cared for women who could not afford a doctor (Rooks, 1997).
Attacks against midwifery accelerated in the early 1900s, when medicine became a profession for profit and male physicians became eager for the revenues of childbirth. Midwifery was nearly eradicated during the first half of the twentieth century as male physicians launched a campaign to discredit midwives, portraying them as immoral, drunken, promiscuous, perverse, and dirty (Davis, 2004). It seemed the smear campaign was working, as the proportion of U.S. births attended by midwives declined from about 50 percent in 1900 to 12.5 percent in 1935. Interestingly, whenever and wherever midwifery declined, maternal mortality and infant deaths from birth injuries increased. In the United States, infant deaths from birth injuries rose by 44 percent between 1918 and 1925, while the overall practice of midwifery contrarily declined (Rooks, 1997). The profession would not have survived were it not for women’s insistence on midwifery care (Davis, 2004).
The modern day natural childbirth and breastfeeding movements in the United States were sparked by several key events: the publication of Grantly Dick-Read’s book Childbirth without fear: The principles and practices of natural childbirth in 1944, the development of the Bradley method of “husband-coached childbirth,” the publication of Marjorie Karmel’s book Thank you, Dr. Lamaze in 1959, and the founding of the International La Leche League in 1956 by seven Chicago-area women (Rooks, 1997).
Though nurse-midwifery had been introduced in 1925 to serve the remote areas of Kentucky (Midwifery, n.d.), a new kind of lay midwife emerged during the 1970s. This midwife had little, if any, training, developed her practice outside of the established healthcare system, and was truly “lay.” Eventually, some of these lay midwives developed their own more or less formal education programs to assist others who wanted to become midwives (Rooks, 1997).
After nearly a century of attacks on the profession, the proportion of births attended by midwives increased once again during the 1980s and the first half of the 1990s. By 1994, midwives attended nearly 6 percent of the births in the United States. That same year, a process for examining and certifying the competence of direct-entry midwives was established bythe North American Registry of Midwives (NARM) which began certifying midwives with the title Certified Professional Midwife orCPM. The term Licensed Midwifeor LM designates a direct-entry midwife who is licensed by the state in which she practices (Rooks, 1997). Licensure for direct-entry midwives is currently available in 24 states (Midwifery, n.d.). The terms CPM, LM, and CM (Certified Midwife, a term used in only three states) all refer to a direct-entry midwife, who has learned through self-study, apprenticeship, a private midwifery school, or a college- or university-based program separate from nursing. The other route to become a midwife in the U.S. includes certification by the American College of Nurse-Midwives (ACNM), which bestows the title Certified Nurse-Midwife or CNM to women and men who are educated in both nursing and midwifery (Midwifery, n.d.).
The popularity of midwifery appears to be on the rise again in the United States as obstetricians become more and more technology-driven, fearful of malpractice suits, and impersonal due to client overload. Women seeking a vaginal birth after cesarean, vaginal breech, or twin delivery are running out of options as hospitals and obstetricians increasingly deny these options, deeming them too high risk to deliver vaginally. In a number of states which license midwives, practice regulations prohibit them from attending these higher risk births, forcing them underground. However, not all states are hostile toward midwives. New Mexico is the most midwife-friendly state, with nearly one-third of births attended by a midwife. In 2004, midwives in New Mexico actually outnumbered obstetricians. Twenty-five of the nation’s 175 birth centers are located in Texas, while twelve states have no birthing centers at all (Block, 2007). Laws and regulations today still vary widely from state to state.
This history of midwifery worldwide and in the United States is a story filled with struggles and successes. But through it all, whether thriving or narrowly surviving, midwifery has proven its resilience time and time again. The profession will live on as long as women and their supporters insist on the best available care, no matter the cost.
Reference List
Block, J. (2007). Pushed: The painful truth about childbirth and modern maternity care.Cambridge, MA: Da Capo Press.
Davis, E. (2004). Heart & hands. Berkeley, CA: Celestial Arts.
The Holy Bible.New International Version. International Bible Society: 1984.
Midwifery (n.d.).In Wikipedia, the free encyclopedia.Retrieved from
Rooks, J. P. (1997).Midwifery & childbirth in america. Philadelphia: Temple University Press.