AMERICAN PUBLIC UNIVERSITY SYSTEM

Charlestown, West Virginia

Causes of the Formation of Nurse Midwifery in the United States During the Early Twentieth
Century

Submitted by

Elizabeth Ping

4142216

HIST501 A003 Sum 10

Submitted to the Department of History

September 22, 2010

 1

During the early twentieth century, the practice of midwifery in the United States

nearly became nonexistent because midwifery came to be viewed as a problem. This view

arose from the untrained, unregulated, and ignorant status of midwifery’s birth attendants,

which were generally thought by physicians of that period as contributors to the high

maternal and perinatal mortality rates. The remaining midwives could respond in only one of

two ways: abandon midwifery altogether or join another occupation. Choosing to adjunct

with nursing, midwifery persisted in a hybrid form of nurse and midwife by capitalizing on

the strength of an already established profession. Research suggests that the causes of the

formation of this new field of nursing were multifold and originated from several sources,

including male obstetricians’ campaigns against midwifery (known today as the “midwifery

debate”), British influences on the culture of midwifery, and the socioeconomic climate of

the time. This paper unites the midwifery debate, which is the most discussed topic of the

existing historiography, with other, less commonly mentioned factors, such as the effects of

cultural, economical, and international changes concerning midwifery and nursing.

I.

The Midwifery Debate

Nurse midwifery largely arose from the fact that the general attitude toward female-

attended birth had shifted from a positive view to a negative one during the 1930s.

Specifically, the following occurrences constituted the “midwifery problem or controversy,”

which led midwifery to fall out of favor with physicians: the high mortality rates of both

women and infants; new, sophisticated tools employed by medical professionals that

shortened the time of labor; the attitude that midwives were only acceptable for the poor; and

the prevailing attitude that males were better suited for obstetrics than female midwives.
 2

The Burgeoning Field of Obstetrics

Many physicians coveted the lucrative business that midwives controlled.1 In 1910,

the field of obstetrics was beginning to emerge as a male-dominated medical specialty that

directly competed with midwifery, which still participated in 50 percent of births and

accounted for a loss of revenue for physicians approximating five million dollars each year.2

Previously, the study of obstetrics had not been considered essential to the medical

community, and few institutions offered obstetric programs.3 Obstetrical physicians, instead

of functioning as complementary healers to midwives, advocated for the elimination of

midwifery.4 However, these physicians faced several obstacles, including the fact that many

physicians were incompetent in providing maternity care and the fact that there was a severe

deficiency in competent teachers of obstetrics other than those midwives who were already

providing maternity care.5

Furthermore, statistical analysis of mortality rates during that time failed to show that

physicians provided better care than midwives and suggested that women giving birth were

more likely to receive inferior care if they were attended by a physician.6 To circumvent

these findings, physicians argued that resources would be wasted if both physicians and

midwives received increased training and that only physicians should have access to the

1
Paula Ford-Marting and Elisabeth A. Avron, The Everything Birthing Book: Know all your
Options and Choose the Method that is Right for you. (Avron: MA, Adam's Media, 2004), 4.
2
Barbara Ehrenreich and Deirdre English, Witches, Midwives, and Nurses: A History of Women
Healers. (New York: NY, The Feminist Press, 1993), 33-34.
3
Helen Varney, Jan Kriebs, and Carolyn Gegor, Varney’s Midwifery (Sudbury: MA, Jones and
Bartlett Publishers, 2004), 7.
4
Barbara Ehrenreich and Deirdre English, Witches, Midwives, and Nurses: A History of Women
Healers. (New York: NY, The Feminist Press, 1993), 33-34.
5
Edwin Van Teijilingen, and others, eds., Midwifery and the Medicalization of Childbirth:
Comparative Perspectives (Hauppauge: New York, Nova Science Publishers, 2004), 22.
6
Ibid., 23.
 3

better educational programs.7 However, once these difficulties were overcome, physicians

felt that their care would far outstrip their midwife counterparts and that poorer women

would choose midwives instead of physicians because the midwives would charge less.

The Flexner Report

The Flexner Report of 1910 was a huge blow to the practice of midwifery in the

United States. Essentially, the Flexner Report deemed medicine not practiced under the

pretense of science illegal.8 This was founded on the belief that the validity of "regular" or

allopathic medicine rested solely upon physicians practicing with a basis in scientific

methods. Moreover, the Flexner Report marked the turning point in the war against

midwifery by stating that one of its goals was to eliminate midwives in order to pave the way

for obstetrical physicians.9

The Flexner Report called for an increase in education for physicians, particularly

those who were white and male.10 This was partially a result of its finding that a physician

graduating from medical school had only seen approximately one birth on average.11

Subsequently, births were moved to a hospital setting where physicians could gain practical

experience in delivering babies; as a direct result, midwives were left with fewer women to

care for. Similarly, physicians had no interest in providing additional education to midwives

8
Randall E. Balin, ed., Trends in Midwifery Research (New York, Nova Science Publishers, 2005),
17.
9
David Stewart, Five Standards for Safe Childbearing (Marble Hill: MO, Quality Books, 1998),
90.
10
Christa Craven, Pushing for Midwives: Homebirth Mothers and the Reproductive Rights
Movement (Philadelphia: PA, Temple University Press, 2010), 28.
11
Robbie Pfeufer Kahn, Bearing Meaning: The Language of Birth (Illinois, University of Illinois,
1995), 192.
 4

and actually wanted to limit their educationally opportunities.12 Above all, the American

Medical Association (AMA) sought to control state requirements of midwifery education.

Eventually, grants were given to train the lay midwives according to the Flexner Report’s

suggested guidelines. However, the AMA required that these lay midwives were taught to

identify all women who were at risk for pregnancy complications, which meant that many

women automatically were sent for physician consultation, which limited the practice of

midwifery.13

Traditional Midwives

Physicians wanted the stereotypical view of an uneducated birth attendant to remain

in the public's mind. Physicians blamed midwives for the plethora of disorders of the time,

namely, puerperal sepsis and neonatal opthalmia; furthermore they called midwives

"hopelessly dirty, ignorant, and incompetent."14 This was largely because immigrants were

known to use midwives that were native to their own ethnic groups, which contributed to the

utilization of midwives being seen as a service only employed by women of lower economic

status even though midwives in countries such as Germany were often required to pass

difficult exams in order to be qualified to practice.15 One of the major proponents of

eliminating midwifery in the United States was Dr. Williams who believed that infection

12
Barbara Blair and Susan E. Cayleff, Wings of Gauze: Women of Color and the Experience of
Health and Illness (Detroit: MI, Wayne State University Press, 1993), 196.
13
Barbara Blair and Susan E. Cayleff, Wings of Gauze: Women of Color and the Experience of
Health and Illness (Detroit: MI, Wayne State University Press, 1993), 197.
14
Barbara Ehrenreich and Deirdre English, Witches, Midwives, and Nurses: A History of Women
Healers. (New York: NY, The Feminist Press, 1993), 32.
15
Edwin Van Teijilingen, and others, eds., Midwifery and the Medicalization of Childbirth:
Comparative Perspectives (Hauppauge: New York, Nova Science Publishers, 2004), 21.
 5

rates could be lowered “more speedily by radical improvement in medical education than by

attempting the almost impossible task of improving midwives.”16

The drive to achieve medicalization of childbirth was largely based on the assumption

that technology is always superior and the opinion that "labor is normal except in

retrospect."17 Another major proponent for the ablution of midwifery was Dr. Delee who

perpetuated the idea that childbirth was a pathological process instead of a normal

physiological process by arguing “only a small minority of women escape damage.”18 He

speculated that nature might not have intended women to deliver babies without assistance

and that they were “used up in the process of reproduction” like salmon. Furthermore, Delee

revealed his personal thoughts on the birthing process by advocating for the routine use of

forceps during birth and planning for sedated labor so that surgical interventions, such as

episiotomies and repairs, could be performed. In this way, Delee believed that assisting labor

with technology and concentrating on prevention of injury was safer than allowing a woman

to injure her pelvic floor and suffer through the process of labor.19 The attitude that those

assisting in childbirth should “do something” and take a more active role in the delivery

process was starting to take hold, and the labor room became more analogous to the

operating room.20

Furthermore, physicians needed to prove that non-physicians should not assist in

delivering babies because if non-physicians could give maternal care, physicians could not

16
Judith Pence Rooks, Midwifery and Childbirth in America (Philadelphia: PA, Temple University
Press, 1997), 25.
17
Edwin Van Teijilingen, and others, eds., Midwifery and the Medicalization of Childbirth:
Comparative Perspectives (Hauppauge: New York, Nova Science Publishers, 2004), 22.
18
Judith Pence Rooks, Midwifery and Childbirth in America (Philadelphia: PA, Temple University
Press, 1997), 25.
19
Ibid., 26.
20
G. J. Barker-Benfield, The Horrors of the Half-Known Life: Male Attitudes Toward Women and
Sexuality in Nineteenth-Century America (New York: NY, Routledge, 2000), 71.
 6

charge high fees for their services.21 The inclusion of forceps and anesthesia by physicians

created exclusivity in this new field of medicine because ethnic immigrant midwives could

not provide these services, and over time, midwives became viewed as “mystical,

rudimentary, and obsolete.”22 Without doubt, this did not help the previously held view by

private and academic physicians that midwives were poor, drunken, unprincipled, rough,

“relics of barbarism,” and at times “criminal abortionists.”23 Ultimately, the movement of

laboring mothers from the home setting to the hospital setting decreased midwife-attended

births of Caucasians to a low of five percent by the year 1935.24

Gender Bias

Physicians played upon the generally accepted stereotype that hormones caused

female midwives to make irrational decisions while assisting during the birthing process to

play on the fears that women already have about the birthing process.25 In addition, it did not

help that the status of women at the turn of the century was low.26 Equally important, male

physicians argued that intense academic studying would shock a woman’s reproductive

organs and that a women’s uterus and central nervous system did not allow rendered her

incapable of learning scientific medicine.27 Consequently, physicians argued that women

2
21
Edwin Van Teijilingen, and others, eds., Midwifery and the Medicalization of Childbirth:
Comparative Perspectives (Hauppauge: New York, Nova Science Publishers, 2004), 23.
22
Barbara Blair and Susan E. Cayleff, Wings of Gauze: Women of Color and the Experience of
Health and Illness (Detroit: MI, Wayne State University Press, 1993), 196.
23
Judith Pence Rooks, Midwifery and Childbirth in America (Philadelphia: PA, Temple University
Press, 1997), 25.
2
24
Edwin Van Teijilingen, and others, eds., Midwifery and the Medicalization of Childbirth:
Comparative Perspectives (Hauppauge: New York, Nova Science Publishers, 2004), 24.
2
25
Paula Ford-Marting and Elisabeth A. Avron, The Everything Birthing Book: Know all your
Options and Choose the Method that is Right for you. (Avron: MA, Adam's Media, 2004), 4.
26
Helen Varney, Jan Kriebs, and Carolyn Gegor, Varney’s Midwifery (Sudbury: MA, Jones and
Bartlett Publishers, 2004), 7.
27
Barbara Blair and Susan E. Cayleff, Wings of Gauze: Women of Color and the Experience of
Health and Illness (Detroit: MI, Wayne State University Press, 1993), 196.
 7

delivered by women was not appropriate and directly challenged the ancient Athenian law,

which had persisted for centuries, that the ideal birth attendant was a woman too old to bear

children herself and had given birth to at least one child.28 Specifically, Dr. Howard Haggard

said that this belief was preposterous stating, “in effect as if it had been said that the

requirements for a surgeon were that he had passed the age of fighting and had been

wounded.”29

Some suggest that the midwifery debate was partly caused by males desiring to

dominate over an occupation that was female centered.30 This control pervaded hospitals

where laboring mothers were viewed as patients in need of medical management and the

changing view that a pregnancy is an illness that needs to be treated.31 The control of

women’s reproductive patterns was not necessarily new, and as early as 1825, physicians

were advising women about how to choose the best mates and what to do during pregnancy

from “the earliest formation of the embryo.” A century later, during the midwifery

controversy, physicians continued to support the belief that males should counsel women,

and they promoted these feelings by actively distributing pamphlets that informed women

about the dangers of choosing a female midwife.32

II.

British Influences

28
G. J. Barker-Benfield, The Horrors of the Half-Known Life: Male Attitudes Toward Women and
Sexuality in Nineteenth-Century America (New York: NY, Routledge, 2000), 70.
29
Ibid., 71.
30
Edwin Van Teijilingen, and others, eds., Midwifery and the Medicalization of Childbirth:
Comparative Perspectives (Hauppauge: New York, Nova Science Publishers, 2004), 24.
31
Ibid., 27.
32
Paula Ford-Marting and Elisabeth A. Avron, The Everything Birthing Book: Know all your
Options and Choose the Method that is Right for you. (Avron: MA, Adam's Media, 2004), 4.
 8

One major consequence of the burgeoning subfield of obstetric medicine was that

it worsened the care women received.33 In the years after the Flexner Report resulted in

the banning and limiting of midwifery in state after state, studies found that infant

mortality rates were actually rising instead of decreasing. This was seen to be caused by

the drive to push midwives out of their occupations, which led to worse outcomes. To

this end, there were differing opinions among the medical community on the exact

function midwives should serve if they were allowed to persist.34 Due to nursing’s

existing profession, the good outcomes obtained by Mary Breckinridge’s nurse

midwifery program in the mountains of Kentucky, and the success Great Britain enjoyed

in utilizing nurse midwives as the primary health care practitioners of women, some

proposed that it would be a worthy effort to train nurses in obstetrical care.

Scope of Practice

Not all physicians practicing during the early twentieth century were against

midwives. In fact, Dr. Fred Taussig believed that only nurses should receive training in

obstetrics and coined the term “nurse midwifery” in 1914.35 This minority view was

based on a couple of considerations. The first consideration was the revelation that

physicians were subject to spreading the same type of infection-related diseases as

midwives were.36 In addition, physicians were accused of often being too quick to use the

type of advanced surgical tools and procedures that could do more harm than good to
33
Gary Null and Barbara Seaman, For Women Only: Your Guide to Health Empowerment (New
York: NY, Seven Stories Press, 1999), 648.
34
Helen Varney, Jan Kriebs, and Carolyn Gegor, Varney’s Midwifery (Sudbury: MA, Jones and
Bartlett Publishers, 2004), 8.
35
Brian Burtch, Trials of Labour: The Re-emergence of Midwifery (Quebec City, McGill-Queen's
University Press, 1994), 82.
36
Gary Null and Barbara Seaman, For Women Only: Your Guide to Health Empowerment (New
York: NY, Seven Stories Press, 1999), 648.
 9

both the fetus and the mother. Instead of a physician, a woman with advanced nursing

training who had learned how to, in essence, sit on her hands and be more patient with

women in labor could serve as the model for maternity care. Another consideration was

that poor women often could not afford the services provided by a physician and

therefore received little or no care.37 Nurses with advanced training could serve indigent

women without having to charge the exorbitant fees that physicians require to maintain

their status in society.

Essentially, nursing’s established nurse practice acts and scopes of practice

protected nurse midwives from harassment and the legal obstacle of practicing without a

license and became the idyllic profession for merging with midwifery; especially, in the

poorer communities that could not afford the services of a physician.38 Nurse practice acts

that were initially started as a way for states to establish certain standards of care were

already starting to take effect when the Flexner Report advocated for medicine move

toward professionalization and standardization. Accordingly, nurses were licensed by the

states in which they worked and they could not be charged with practicing without a

license in the same way that midwives who lacked a professional organization could.

Mary Breckinridge

Mary Breckinridge, the founder of nurse midwifery in the United States, proposed

the theory that nursing could be broadened in the area of public health, especially in the

37
Helen Varney, Jan Kriebs, and Carolyn Gegor, Varney’s Midwifery (Sudbury: MA, Jones and
Bartlett Publishers, 2004), 930.
38
Lynette A. Arment, Professional Issues in Midwifery (Sudbury: MA, Jones & Bartlett Publishers,
2007), 184.
 10

poorest of communities where physicians usually chose not to practice. For her social

experiment, she chose a geographically isolated region of the United States devoid of

practicing physicians where she had access to her family’s political ties.39 In Europe,

midwife-attended births posed minimal complications in terms of morbidity and mortality

and she felt that this model could be emulated in America.40 Breckinridge exclaimed, "In

France, midwives were not nurses. In America, nurses were not midwives. In England,

trained women were both nurses and midwives."41 Emulating the British midwifery

model of care, Breckinridge decided to import British-trained nurse midwives to America

and set them to work in the Appalachian Mountains.42 In addition, since specialized

nursing training in midwifery did not exist, Breckinridge chose to be trained as a nurse

midwife in Great Britain.43

However, with the onset of World War II, many of the British nurse midwives

returned to England in order to be with their families; consequently, Breckinridge was

forced to begin training American nurse midwives.44 However, until the American nurse

midwives completed their training, Breckinridge was without nurse midwives to care for

the many Appalachian families that relied on her Frontier Nursing Service for all of their

medical needs. Finally, after some initial financial shortcomings, Breckinridge started the

Frontier School of Nursing in 1939. The Frontier School of Nursing granted graduate

degrees to women who desired to advance their education in the field of midwifery and

39
Mary Breckinridge, Wide Neighborhoods: A Story of the Frontier Nursing Service (Lexington:
KY, University Press of Kentucky, 1952), 158-159.
40
Brian Burtch, Trials of Labour: The Re-emergence of Midwifery (Quebec City, McGill-Queen's
University Press, 1994), 82.
41
Breckinridge, 111.
42
Marie Bartlett, The Frontier Nursing Service: America's First Rural Nurse-Midwife Service and
School (Jefferson: NC, McFarland & Company, 2008), 17.
43
Breckinridge, 124.
44
Ibid., 140.
 11

public health.45 In this way, both the arrival and departure of British midwives set the

stage for nurse midwifery to take hold in the United States.

III.

Cultural Changes

Although much has been written about the beginning of nurse midwifery in the

existing historiography, few sources mention the changes that occurred in the lives of

women and the African American midwives or “granny midwives” that influenced the

decline of the lay midwife to the brink of extinction.

The Changing Role and Attitudes of Women

During the turn of the century, more than ever before, families became dependent on

women attaining outside employment.46 Since women were no longer surrounded by other

women of relation to discuss matters of fertility and parturition, this led to a reliance on

advice from medical professionals concerning reproductive concerns. Consequently, the long

heritage of familial and oral traditions for the birthing process broke and only the elderly,

who no longer needed it, retained this once common knowledge. When women turned more

to hospitals and physicians for maternity services, fewer midwives were needed. This was

furthermore compounded by the fact that during World War I, some hospitals offered free

food and housing for delivering mothers, which attracted some of the poor away from

midwife care since midwives were not allowed hospital privileges.47

45
Ibid., 324-325.
46
Judith Pence Rooks, Midwifery and Childbirth in America (Philadelphia: PA, Temple University
Press, 1997), 22.
47
D. Wier, “The Parkland School of Nurse Midwifery: History of Midwifery in the US” Parkland
Memorial Hospital, 1996, http://www.neonatology.org/pdf/midwifery.history.pdf (accessed September 10,
2010), 2.
 12

The explosion of motorized vehicles during the first half of the century also had an

effect on the birthing practices of women. In years past, women had little choice but to give

birth in their own environments because transportation methods were limited and slow. The

proliferation of automobiles allowed women to travel to the hospital for the birthing process

instead of delivering in their own homes.48 A cultural attitude change among American

women during the turn of the century resulted in their desire to be hospitalized in order to

benefit from the care that physicians could provide, such as the possibility of labor without

pain and easy access to emergency equipment if complications were presented.49 In this way,

women believed that they could receive better birthing care in a hospital than in their own

homes, and homebirths became viewed as something to which poor women were disposed.

Remaining Prejudices

Prejudice against African American women was still evident in the early twentieth

century and helped midwifery survive as an occupation, because they were denied access to

certain hospitals.50 Furthermore, poor women who lacked insurance to cover their medical

needs could not afford to stay in the hospital for the birth of their children. Consequently,

granny midwives (often older, southern, African American women) who were not yet banned

by law still carried a large volume of patients to maintain an adequate income and attended to

pregnant woman of ethnic and indigent social status. In short, this meant that midwives still

needed to care for the women no one else wanted to care for, which left a few traditional

midwives to survive against the odds and practice in the periphery.

48
Judith Pence Rooks, Midwifery and Childbirth in America (Philadelphia: PA, Temple University
Press, 1997), 22.
49
Helen Varney, Jan Kriebs, and Carolyn Gegor, Varney’s Midwifery (Sudbury: MA, Jones and
Bartlett Publishers, 2004), 930.
50
Ibid., 930.
 13

At the start of the twentieth century, despite the critical arguments against the safety

and legitimacy of midwifery made by the medical elite, maternal care by midwives

ultimately persisted by providing services to the indigent and underrepresented populations.

The anti-midwifery movement forced midwives to practice under tighter regulations, which

resulted in the art of midwifery joining with nursing through specialized graduate programs.

Today, nurse midwifery has flourished. It enjoys an ever-increasing scope of practice and

receives insurance reimbursement comparable to the compensation received by physicians

for equivalent procedures. Although, nurse midwifery is nowhere near as expansive as its

traditional form, it continues to play an important role in providing adequate health care for

women, participating in 7.6 percent of total births in 2003 and over 10 percent of all vaginal

births.51 Furthermore, Mary Breckinridge’s program, now called the Frontier School of

Midwifery and Family Nursing, continues to graduate advanced practice nurses that work in

all 50 states.52

51
Elizabeth Laura Ettinger, Nurse Midwifery: The Birth of a New American Profession (Columbus:
OH, Ohio State University Press, 2006), 195.
52
D. Wier, “The Parkland School of Nurse Midwifery: History of Midwifery in the US” Parkland
Memorial Hospital, 1996, http://www.neonatology.org/pdf/midwifery.history.pdf (accessed September 10,
2010), 3-4.
 14

Bibliography

Arment A. Lynette. Professional Issues in Midwifery. Sudbury, Jones & Bartlett Publishers,
2007.

Balin, E. Randall, ed. Trends in Midwifery Research. New York: Nova Science Publishers,
2005.

Barker-Benfield, G. The Horrors of the Half-Known Life: Male Attitudes Toward Women
and Sexuality in Nineteenth-Century America. New York: Routledge, 2000.

Bartlett, Marie. The Frontier Nursing Service: America's First Rural Nurse-Midwife Service
and School. Jefferson: McFarland & Company, 2008.

Blair, Barbara and Susan E. Cayleff., Wings of Gauze: Women of Color and the Experience
of Health and Illness. Detroit: Wayne State University Press, 1993.

Breckinridge, Mary. Wide Neighborhoods: A Story of the Frontier Nursing Service.

Lexington: University Press of Kentucky, 1952.

Burtch, Brian. The Trials of Labour: The Re-emergence of Midwifery. Quebec City, McGill-
Queen's University Press, 1994.

Craven, Christa. Pushing for Midwives: Homebirth Mothers and the Reproductive Rights
Movement. Philadelphia: Temple University Press, 2010.

Ettinger, L. Elizabeth. Nurse-Midwifery: The Birth of a New American Profession.

Columbus: Ohio State University Press, 2006.

Ehrenreich, Barabara and Deirdre English. Witches, Midwives, and Nurses: A History of
Women Healers. New York: The Feminist Press, 1993.

Ford-Martin, Paula and Elisabeth A. Aron. The Everything Birthing Book: Know all your
Options and Choose the Method that is Right to you. Avon: Adam's Media, 2004.

Kahn, Pfeufer Robbie. Bearing Meaning: The Language of Birth. Illinois: University of
Illinois, 1995.

Null, Gary and Barbara Seaman, For Women Only: Your Guide to Health Empowerment
New York: Seven Stories Press, 1999.

Rooks, Pence Judith. Midwifery and Childbirth in America. Philadelphia: Temple University
Press, 1997.

Stewart, David. Five Standards for Safe Childbearing. Marble Hill: Quality Books, 1998.
 15

Van Teijilingen, Edwin, George Lowis, and Peter McCaffery. eds., Midwifery and the
Medicalization of Childbirth: Comparative Perspectives. Hauppauge: Nova Science
Publishers, 2004.

Varney, Helen, Jan Kriebs, and Carolyn Gegor, Varney’s Midwifery Sudbury: Jones and
Bartlett Publishers, 2004.

Wier, D. 1996. “The Parkland School of Nurse Midwifery: History of Midwifery in the US”
Parkland Memorial Hospital. http://www.neonatology.org/pdf/midwifery.history.pdf
(accessed September 10, 2010).