For the past several years, Community Solutions has raised awareness of poor maternal and infant health outcomes by advocating for policy changes that would increase the availability of data; eliminate racism, discrimination and prejudice in the health care system; and to increase insurance access for low-income mothers. Recently, however, we have identified that for favorable birth outcomes, women need more than access to care, they need a combination of clinical skills and relationship-based care. For this reason, we have supported doulas, non-clinical birth support professionals, as well as midwives as key parts of a pregnant woman’s support team. While midwives are known for delivering babies for low-risk women, many midwives in the United States are highly trained health care professionals who offer a range of services for women at all stages of life. These services may include:
- General health care services
- Annual gynecologic exams
- Family planning needs
- Treatment of sexually transmitted infections
- Care for pregnancy, labor and birth
- Menopause care
Many studies, both retrospective and systematic, have produced the same results: women who initiated care with a midwife demonstrated better results compared to those whose care was led by or initiated by a physician.
Midwives do, however, specialize in the normal process of pregnancy, birth and the post-partum period. They are able to manage many common obstetric scenarios and complications without obstetrician oversight, although many midwives do work in collaboration with hospitals and/or physicians. A midwife usually seeks to eliminate or minimize the institutionalization of birth and therefore strays away from unnecessary technological interventions, centering pregnancy and birth as normal life processes. Similar to doulas, midwives provide support to mothers throughout pregnancy including emotional support, advice on nutrition, monitoring gestational progress and suggesting strategies to help ease labor.
Historic overview of midwifery in the United States
As compared with many other wealthy and industrialized countries, the United States has an incredibly complex history with birth work, midwifery, childbirth and general maternity care. For most of Colonial America and well into the 19th century, all births occurred in the home, an overwhelming majority of which were attended by midwives who also provided most medical care for the entire family. British women, whose skills were passed down informally and largely rooted in experience and spiritual healing, were quickly able to adapt their practices once they arrived in the American colonies. West African midwives, who in addition to experience and spiritual healing had extensive knowledge of herbs, came to America as slaves and had to attend the births of both Black and white women on plantations. Slave midwives served an incredibly important role in the slave community from sharing and thus preserving African culture and traditions, passing on general health care advice and serving as community conduits. Slave midwives were more mobile than field hands as they were able to care for pregnant women and deliver children on surrounding plantations who did not have midwifes, therefore facilitating communication between many friends and families who had been broken up in slave trades.[1] Because of this crucial role, many Black women continued providing midwifery services to poor women throughout the rural South after emancipation.
Despite the increase in hospital deliveries between 1915 and 1930, maternal mortality remained steady and the number of infant deaths from birth injuries increased between 40 and 50 percent.
As medicine became professionalized in the United States, births became more institutionalized. In 1900, fewer than 5 percent of women gave birth in hospitals but by the early 1920s up to 50 percent of women gave birth in hospitals.[2] The idea of anesthetics and medical advances such as twilight sleep during labor and childbirth became very popular among women of reproductive age who previously faced birth with dread about pain and the fear of death.[3] Many of these innovations, however, could only be used in a hospital setting under the care of a physician. Physicians, all of whom were male and many of whom now received formal education and training from medical schools, viewed midwifery as competition and were uninterested in having who they perceived as uneducated women working alongside them in a hospital setting. Thus, midwifery care was reserved almost exclusively for those who were unable to afford hospital births and those who were excluded from hospitals because of their skin color. While few Black hospitals did exist, they were notorious for poor care. Midwives not only charged significantly less than physicians for their services but also provided a variety of services which neither hospitals nor physicians could offer such as cleaning the house, preparing meals and looking after other children.[4]
By the mid-1930s, while the number of physicians attending births had climbed exponentially since the turn of the century, this seemed to negatively impact birth outcomes. A 1933 report issued by The White House Conference on Child Health and Protection found that despite the increase in hospital deliveries between 1915 and 1930, maternal mortality remained steady and the number of infant deaths from birth injuries increased by between 40 and 50 percent.[5]
In spite of this and the fact that trade associations began to pick up steam, obstetricians and gynecologists continued to seek respect for their specialties by blaming poor outcomes on “the midwife problem.” Addressing this problem, of Black midwives in particular, consisted of attacking them based on intelligence, character and hygiene.[6] Dr. Thomas Darlington, a former Commissioner of Health for New York City was one of the first to define the extent of the problem. In 1911, he published an article in the American Journal of Obstetrics and Diseases in Women and Children titled “The Present Status of the Midwife” where he stated:
“We know in general that the midwife is commonly employed in this country by the negro and alien populations as well as by many native-born of foreign parentage… Reports upon midwifery investigations made in several of our large cities, together with observations from those who confront the problem in the rural districts, prove conclusively that the midwife, with very few exceptions the country over, is dirty, ignorant and totally unfit to discharge the duties which she assumes.” [7]
Meanwhile Black midwives, sometimes known as “Granny” midwives, continued to be the center of health and social support in the Black community through the mid-1900s, delivering approximately 90 percent of Black women’s babies in the South.[8] While midwifery schools and formal training programs had emerged by this point, in part because of the passage of the Sheppard-Towner Act [9], many Black women had limited education or were illiterate as a result of racial discrimination and poverty and thus practiced in secret, relying on the teachings of their ancestors and deep religious beliefs for their practices which often occurred without monetary compensation. These women, known as lay midwives, were not incorporated into a national system of public health and had no national professional organizations to defend their existence within the field of medicine unlike in other industrialized countries such as Japan, Germany and England.
Although the demand for midwifery services, especially among white families, continued to fall in the early 1900s, physician-led campaigns against “the midwife problem” waged on. Many physicians, however, began to concede that abolition of midwifery was unattainable and instead advocated for the licensing and increased supervision of midwives instead.[10] Between licensing requirements, which varied considerably across states and intended to prohibit lay midwives, and the Sheppard-Towner Act which enforced stricter guidelines and certification requirements for midwife training programs, Black “Granny” midwives were systematically ousted from practicing.[11]
Midwife use began a slow rebirth in the mid-1900s as attitudes about childbearing and hospital care began to shift thanks to a rise in the use of Caesarean sections, many Black midwives remained boxed out of the profession as Certified Nurse Midwives (CNMs) were preferred to lay midwives.[12] CNMs are Registered Nurses (RNs) with an additional training in midwifery. This along with help of their professional organization, the American College of Nurse-Midwives, allowed them to quickly be recognized as primary health care providers which in turn allowed them to gain reimbursement from private insurance companies, Medicare, Tricare and Medicaid, and also gave them prescriptive authority in all states.[13] While CNMs are able to practice in all birth settings including private homes, clinics, birth centers, physicians’ offices and hospitals, a majority choose to primarily attend births in a hospital setting.
Along with CNMs, today the most commonly practicing midwives in the United States are Certified Midwives (CMs), Certified Professional Midwives (CPMs) and Direct-Entry Midwives (DEM). Generally, CMs graduate from a master’s level midwifery education program and have similar training to CNMs but are not required to have the nursing component, therefore not all states license them. On the other hand, CPMs are often required to complete a certification and accreditation process through the North American Registry of Midwives (NARM) to receive a credential. While NARM is a national organization, licenses are issued by states and not all states recognize the CPM in midwife licensure. Many CPMs choose to not work alongside physicians and thus they generally work in private homes or birth centers. While any non-nurse midwife can be referred to as a DEM, a lay midwife (LM) entered the profession with no certification, licensure or any formal education. Often these midwives began by engaging as an apprentice to a practicing midwife.
Having a midwife is a common practice in most developed countries because of the positive birth outcomes associated with their presence.
Most midwives in the United States are CNMs who along with CMs attended more than 350,000 births, which represented 85 percent of all midwife-attended births and 9.1 percent of total United States births in 2017. Of these CNM/CM attended births, 94.1 percent occurred in hospitals, 3.2 percent in freestanding birth centers and 2.6 percent in homes. While midwives are most known for attending births, 53.3 percent of CNMs/CMs identify reproductive care as their main responsibility and 33.1 percent identified primary care as the main responsibility in their full-time positions. This includes performing annual exams, prescribing birth control and contraceptive care, parenting education, nutrition counseling, etc.[14]
Having a midwife is a common practice in most developed countries because of the positive birth outcomes associated with their presence.[15] Many studies, both retrospective and systematic, have produced the same results: women who initiated care with a midwife demonstrated better results compared to those whose care was led by or initiated by a physician. A large, continuously updated systematic Cochrane review[16] of small-scale research studies in midwifery-led care has shown favorable birth outcomes for women with low-risk pregnancies. Women who experienced midwife-led care were less likely to have regional anesthesia for pain management or experience operative vaginal deliveries, episiotomies or preterm births before 37 weeks. A similar systematic review found midwife care to be associated with lower rates of Cesarean deliveries, lower rates of third and fourth-degree lacerations, and higher rates of initiation of breastfeeding among women delivered by CNMs.[17]
[1] Varney, Helen. Thompson, Joyce. (2015). A History of Midwifery in the United States. Springer Publishing Company.
[2] https://midwiferytoday.com/web-article/history-midwifery-childbirth-america-time-line/
[3] Goode, K. (2014). Birthing, Blackness, and the Body: Black Midwives and Experiential Continuities of Institutional Racism [Doctoral dissertation, The City University of New York]. Academic Works, CUNY.
[4] Litoff, J. (1978). Forgotten Women: American Midwives at the Turn of the Twentieth Century. The Historian, 40(2), 235-251.
[5] Ibid
[6] Sano, Y. (2019). “Protect the Mother and Baby”: Mississippi Lay Midwives and Public Health. Agricultural History, 93(3), 393-411. doi:10.3098/ah.2019.093.3.393
[7] Darlington, T. (1911) The Present Status of the Midwife. The American Journal of Obstetrics and Diseases of Women and Children, Volume 63.
[8] Ibid
[9] Passed by Congress and signed by President Harding in 1921, the Sheppard-Towner Act, also known as the National Maternity and Infancy Protection Act provided federal funds to states to establish programs to educate people about prenatal health and infant welfare
[10] Anderson, D. et al. (2016). The Effect of Occupational Licensing on Consumer Welfare: Early Midwifery Laws and Maternal Mortality. National Bureau of Economic Research.
[11] Hoffman, C. Diaz-Camacho, V. (2020). Birthing Battle The Struggle for Equity in Maternal Health Care. Flatland.
[12] Wolf, J. 2018. American women are having too many caesareans, at too much risk. Los Angeles Times.
[13] Ibid
[14] American College of Nurse-Midwives Fact Sheet: https://www.nber.org/system/files/working%5Fpapers/w22456/w22456.pdf
[15] Tikkanen, R. et al. (2020). Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries. The Commonwealth Fund.
[16] A Cochrane Review on continuity of midwife care was first published in 2004, and most recently updated in 2016. As more trials have been added to the Review, uncertainties in the original finds have been reduced. Both the World Health Organization and the United Kingdom’s Department of Health have identified this Cochrane Review as a priority topic for updating.
[17] Moore, J. et al. (2020). Improving Maternal Health Access, Coverage, and Outcomes in Medicaid. Institute of Medicaid Innovation.
