Running head: NURSE MIDWIFERY AND BIRTHING CENTERS IN AMERICA 1

Historical Development of Nurse Midwifery and Birthing Centers in America

Kathryn Sibbold CNEP 81 and Elizabeth Ping CNEP 81

Frontier School of Midwifery and Family Nursing

PC 601: History of Midwifery

November 6, 2010
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Abstract

Midwifery in the United States has undergone many transformations since Colonial times in

terms of practices and policies. Various factors influenced the formation of nurse midwifery

during the early twentieth century. Criticism by male obstetricians toward traditional midwives

threatened midwifery’s existence; however, some saw nurse midwifery as the solution to

providing maternity care to indigent populations. Eventually, nurse midwives established free-

standing birth centers as nurse midwives gained wider acceptance for providing quality, women-

centered care. Nurse midwifery has since expanded to include its own professional organizations,

and today nurse midwives practice in a variety of settings and provide care to women across the

age continuum.

Keywords: nurse midwifery, history, birth centers

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Historical Development of Nurse Midwifery and Birthing Centers in America

The professional identity of nurse midwifery and widespread application of birth centers

in the United States developed from multiple factors involving the changing social, cultural,

economic, and behavioral perceptions people had concerning women and childbirth. As such,

the major turning points for the history of nurse midwifery and inception of birth centers in the

United States can be illustrated by exploring the people, policies, politics, practice, and payment

methods that summarize the essential elements of midwifery history. By evaluating the

significant contributions that midwives have made, support can be gathered reflecting the

importance that midwifery places in providing excellent maternal and fetal outcomes.

Midwifery

Since ancient times, the practice of midwifery has been empirically passed from woman

to woman; furthermore, few cultures involved male participation during childbirth (Munro &

Spiby, 2010, pp. 57–58). Eventually, midwifery laws, regulations, and educational programs

were developed in Europe and Britain during the middle ages, and Germany passed one of the

first laws regarding midwifery as a profession in 1492 (Rooks, 1997, p. 12). In France,

municipal regulation of midwives required witnesses to attest to the midwife’s moral character,

and an examination of skills had to be passed. However, most midwives were illiterate, older,

and multiparous; they possessed limited knowledge of anatomy and physiology and were

motivated by earning additional income for their families (Kalisch, Kalisch, & Scobey, 2004, p.
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393). By the 1600s, the social status of midwives improved, and midwifery education expanded

due to the work and writing of Louyse Bourgeois, a Parisian midwife (Rooks, 1997, p. 15).

Midwifery practices used by early American settlers were influenced by the birthing

traditions of European and African immigrants (Rooks, 1997, p. 18). As in Europe, childbirth

was primarily a female event that occurred in the home (Ettinger, 2006, p. 6). Midwives focused

on providing emotional support for the laboring woman and intervened occasionally by

employing turning techniques and administering liquor for pain relief. After the birth, the

midwife stayed in the home to ensure the wellbeing of the woman and baby and assist in some of

the basic household chores. Midwifery training mainly consisted of unregulated apprenticeships

resulting in unequally skilled practitioners, and most midwives did not consider themselves

members of a profession. Payment also varied for the services provided by midwives and ranged

from a monetary reward to cheese or bolts of cloth (Mays, 2004; Rooks, 1997).

By the late 18th century, male physicians (who were predominately Caucasian and

middle or upper class) known as “man-midwives” gained acceptance as an alternative to female

midwives (Ettinger, 2006, pp. 6–7). There were multiple factors that attracted birthing women to

choose male physicians: Women desired forceps, bloodletting, and anesthetics that could

potentially save lives and increase comfort; women assumed that physicians possessed more

advanced training in anatomy and physiology than midwives; women assumed that interventions

by physicians during the childbirth process are necessary; and women believed that the male sex

held more prestige over the female sex (p. 7). In the 1920s, these man-midwives or modern-day
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obstetricians challenged birth as a natural process and promoted the movement of birth from the

home to the hospital so that birth could be managed through medical procedures such as

episiotomies and labor inductions (p. 8). As women increasingly desired the predictability, pain

management, and technology that institutions offered, hospital-based births under the guidance

of physicians became the norm by 1935 (p. 10).

The campaign against midwifery coined the “midwifery debate” began in the early 20th

century (Rooks, 1997, p. 24). Physicians viewed midwives as being “hopelessly dirty, ignorant,

and incompetent” and blamed midwives for contributing to puerperal sepsis and neonatal

opthalmia (Ehrenreich & English, 1993, p. 32). Although the Flexner report of 1910 criticized

the state of medical education by illuminating the fact that many graduating physicians had never

attended a birth during their academic career, physicians argued that midwifery should be

eliminated and medical training in obstetrics bolstered (Kahn, 1995, p. 192). This was partly due

to the fact that physicians desired to gain from the lucrative business that midwives had, and

physicians ignored the fact that physicians did not provide better outcomes than midwives

(Ehrenreich & English, 1993; Stewart, 1998; Rooks, 1997). Additionally, the Flexner report

deemed medicine not practiced under a license illegal, and childbirth became viewed as

dangerous, requiring the assistance of physicians (Rooks, 1997, p. 24). Facing almost certain

abolishment, midwives chose to join with the already-established profession of nursing to form

the hybrid nurse/midwife based on the British model of maternity care.

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Public health concerns promulgated the need for nurses with advanced training in

obstetrical care and provided an opportunity for the burgeoning field of nurse midwifery to

expand. The Children’s Bureau conducted research in the early 1900s to gain information about

maternal and child healthcare in the United States. The studies drew attention to the high infant

and maternal mortality rates, compared to Western Europe, which resulted in an increased

interest in promoting prenatal care in the United States (Rooks, 1997, p. 35). In response, the

Maternity Center Association (MCA) addressed the prenatal care needs of women in New York

City by opening one of the first nurse-midwifery programs in the United States, The Lobenstine

Midwifery School in 1934 (p. 38).

In rural Kentucky, Mary Breckinridge proved that nurse midwives could provide

adequate maternity care to women and support the general health needs of the family. She

established the Frontier Nursing Service (FNS), which initially employed British nurse

midwives. The service was set in the Appalachians, a terrain that was so difficult to maneuver

and possessing so many poverty-stricken people that she hoped it would demonstrate that this

type of nursing and maternity care could be duplicated all over the country with less effort

(Breckinridge, 1981, pp. 157–158). Nursing posts were set up over the county, and the nurse

midwives provided home visits for prenatal care and general health complaints. Nurses rode on

horseback to patients’ homes with saddlebags full of medical supplies. Donations from wealthy

families, including the Ford family, contributed in sustaining the service (p. 195). Louis Dublin,

an employee of the Metropolitan Life Insurance Company, studied the first 1,000 deliveries of
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the FNS and found that the lives would be saved if the FNS model were implemented on a larger

scale (p. 312). When Breckinridge’s nurse midwives left the United States during World War II,

Breckinridge established her own school of nurse midwives. The legacy of Breckinridge’s desire

to increase the wellbeing of families persists today as the Frontier School of Midwifery and

Family Nursing has a student body representing all 50 states and multiple countries (Rooks,

1997, pp. 167–168).

Although nurse midwives were gaining a stronger presence in the public health arena,

they still lacked a professional organization to set policies. In 1944, the National Organization of

Public Health Nursing (NOPHN) created a nurse midwifery branch and collected data on current

nurse midwives practicing in the United States (Rooks, 1997, p. 41). When the NOPHN ended

in 1952, nurse midwives tried to find their place among the American Nurses Association (ANA)

and the National League for Nursing (NLN). As a result, nurse midwives who met at the ANA

convention in 1954 decided to form the American College of Nurse Midwifery. Finally, in 1968,

the American College of Nurse Midwifery merged with the American Association of Nurse

Midwives (AANM) to form the American College of Nurse-Midwives (Ettinger, 2006, p. 184).

Birth Centers

The American Public Health Association (APHA) defined a birth center as a health

facility not associated with a hospital where mothers who experience uncomplicated pregnancies

can give birth (1982, para. 5). In 1945, the first birth center, “La Casita,” was created in rural

New Mexico as a place where women who lived too far from the hospital could come to give
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birth (Rooks, 1997, p. 74). Following suit, the MCA established its own freestanding birth

center in Manhattan due to increased rates of dissatisfaction with hospital birth and increased

rates of unsupervised home births in urban areas in 1975. Lubic concluded that “out-of-hospital

birth can be safely managed, providing there is professional supervision of a carefully screened

population” (as cited in Rooks, 2007, p. 74). Thereby, the MCA’s Childbearing Center became

an avenue for nurse-midwives to provide the basic tenets of the birth center concept by giving

quality, inexpensive care to low-risk women by focusing on prevention and early detection of

complications during the antepartum, intrapartum, and postpartum periods in an environment

separate from the hospital (pp. 74–75).

The development of licensing, accreditation, and reimbursement protocols for birth

centers has seen many changes. In 1979, the APHA began endorsing birth centers as an

alternative to hospital births for normal pregnancies (1982, p. 1). As such, it set forth guidelines

for the licensing and regulation of birth centers for state and local health agencies to consult.

These guidelines included the appropriate measures that birth centers should take to provide

maternity care through specific staffing, facility, services, policies, and procedures (pp. 1–7). The

chief policies regarding the welfare of pregnant women included the staffing of licensed birth

attendants, development of an advisory council, possession of adequate equipment for life

support, serving only women who have uncomplicated pregnancies, possession of limited

surgical services, maintenance of careful records of care, and consultation agreements with

obstetrical physicians. By 1988, the Civilian Health and Medical Program of the Uniformed
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Services (CHAMPUS) deemed that birth centers must be accredited, and rules were published

concerning payment methods (Ernst, 1994, p. 132). Currently, birth centers receive most of their

payment by contracting with major health insurance companies such as Aetna, Humana, and

Blue Cross (AABC, 2010, para. 1).

As more women chose birth centers over acute care hospitals, many desired verification

that birth centers could provide safe care (Ernst, 1994, pp. 132–133). In response, a cohort of

11,814 women were admitted to birth centers for treatment during labor that included the

continuous attendance of a nurse midwife, occasional use of tub hydrotherapy, and minimally

invasive procedures. Of these women, there were no maternal fatalities and minimal neonatal

mortalities. The “National Birth Center Study” suggested that birth centers provide safety,

satisfaction, and savings comparable to other birth settings (Rooks et al., 1989). Additionally, the

“National Birth Center Study” suggested that birth centers could assist in appropriately

identifying women who are at a low risk for complications during labor and delivery (Ernst,

1994, p. 133).

In order to champion family-centered births, the MCA became the American Association

of Birth Centers (AABC) became the primary nonprofit organization for promoting national

accreditation, state regulation, research, and quality services for birth centers (AABC, para. 1).

The AABC is currently lobbying, collaborating with other organizations, and promoting birth

research in order to address the different threats to the sustainability of birth centers, which

include exorbitant malpractice insurance rates, the lack of a federally mandated facility fee, and
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insufficient reimbursement for the services that nurse midwives provide (Phillippi, Alliman, &

Bauer, 2009, para. 1).

Midwifery in the United States has grown and developed over time and continues to be

affected by the varying people, political systems, health policies, and payment methods that

make up the American health care system. This is reflective in the way nurse-midwives have

incorporated a wider range of age groups outside of the maternity cycle. The practice of nurse-

midwives now includes adolescents seeking maternity and gynecological care to women who are

perimenopausal and women who have reached menopause (Barger, 2005, para. 7). Likewise,

family planning was added to nurse-midwifery practice after 1965 when the government began

to support initiatives to limit unwanted births (Stone, 2000, p. 10). With the increased use of

technology and blurring between uncomplicated and complicated pregnancies, some nurse

midwives collaborate with physicians in the clinic setting to provide comprehensive care across

the continuum (p. 14). The expansion of nurse midwifery practice to the hospital setting during

the 1950s and 1960s allowed nurse midwives to increase their scope of practice to include

greater technical skills such as episiotomies, intravenous solution, and use of fetal monitors (p.

10). Thus, midwives are not confined entirely to the home environment and birth centers as their

only settings for assisting in deliveries. Ultimately, nurse midwives represent skillful

professionals who have adapted themselves to the differing needs of the women and families

they serve.
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References

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