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

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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 midwiferys 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 femaleattended 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.

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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 the1

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, Varneys 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.

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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

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Randall E. Balin, ed., Trends in Midwifery Research (New York, Nova Science Publishers, 2005),9

17. David Stewart, Five Standards for Safe Childbearing (Marble Hill: MO, Quality Books, 1998), 90. 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), 192.10

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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 Reports 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

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.

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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 notJudith 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), 71.16

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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 womans reproductive organs and that a womens uterus and central nervous system did not allow rendered her incapable of learning scientific medicine.27 Consequently, physicians argued that women2 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, Varneys 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.

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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 womens 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

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.

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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 nursings existing profession, the good outcomes obtained by Mary Breckinridges 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 toGary 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, Varneys 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), 648.33

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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, nursings 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

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

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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 familys 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 and39

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.

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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.4745 46

Ibid., 324-325. 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.

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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, Varneys Midwifery (Sudbury: MA, Jones and Bartlett Publishers, 2004), 930. 50 Ibid., 930.

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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 Breckinridges program, now called the Frontier School of Midwifery and Family Nursing, continues to graduate advanced practice nurses that work in all 50 states.52

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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.

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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, McGillQueen'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.

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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, Varneys 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).