Blazing Trails for Midwifery

The American Association for the History of Nursing is so pleased to partner with Nursing Clio for this special series, which showcases some of the innovative and diverse work being done by historians of nursing across the world. The AAHN holds its annual meeting this week in Rochester, New York, and these essays are windows into the kind of questions and issues being explored at that meeting, by historians who use nurses as a lens through which to understand the intersection between gender, work, and health. Nursing history did not start with Florence Nightingale, nor is it at an end. As nurses continue to make up the largest health care workforce, practicing their art and science in a variety of settings, communities and political contexts, it is more important than ever that we look to where we have been to learn the lessons we need for the future of increasingly complex healthcare systems. Whenever I talk to students or fellow scholars about the significance of nursing history, especially at the moment, I emphasize the significant social role that nurses have played. Nurses have had to negotiate sexism and racism within society, and within their profession. They have been continually challenged by hierarchies of medicine, power, and authority as they attempted to provide care, as historian Susan Reverby has argued, in a society that does not value caring. And they have not always been angels of selfless good. Yet nursing continues to be the most trusted of all the professions, and that trust is something that has been, and continues to be, earned. These essays from the history of nursing demonstrate the complex ways in which nurses have striven to provide careful, compassionate, patient-centered care, and how they have always been agents of social change.

Dr Kylie M Smith
Assistant Professor
Andrew W Mellon Faculty Fellow for Nursing & the Humanities
Emory University, Atlanta Georgia.
Director and Chair of Communications
American Association for the History of Nursing

Childbearing families and maternity care providers have recently faced a barrage of headlines, such as U.S. Has The Worst Rate Of Maternal Deaths In The Developed World, Your Biggest C-Section Risk May Be Your Hospital, and Why is the U.S. Cesarean Section Rate So High?. These articles stem from rising rates of cesarean section births in the U.S. that have not been accompanied by improvements in newborn outcomes but rather by increasing rates of women dying from pregnancy-related complications. Amid this backdrop of fear and risk, the American College of Obstetricians and Gynecologists, working with the American College of Nurse-Midwives, released a statement earlier this year, endorsing approaches to limit interventions during labor and birth, especially for low-risk women.

The wisdom of avoiding unnecessary interventions in childbirth is not news to midwives; this is the approach we have been using for centuries. Midwives traveled to this country with the earliest settlers from Europe, often as slaves. Apprentice-trained midwives also provided at-home care for women of all classes during the colonial era. Childbirth was a social event. Childbearing women were surrounded by family members and neighbors as midwives provided maternity care.¹ Over the course of the nineteenth century, though, as historian Laura Ettinger has pointed out, childbirth “gradually moved from home to hospital, birth attendants changed from female midwives to male physicians, and birthing practices replaced folk healing with scientific medicine.”²

Traditional midwifery gave way to physicians trained in obstetrics who cared for laboring women alongside sick and dying patients. Some scholars argue that this dismantling of home-based midwifery care led to a marked increase in puerperal fever and obstetric interventions, increasing the maternal mortality rate by six-fold, and the infant mortality rate by almost three-fold³. Nonetheless, by the early 20th century, traditional midwifery was significantly diminished.⁴

In response to the alarmingly high maternal and infant mortality rates of the era, public health nurse leaders such as Lillian Wald, Carolyn Conant van Blarcom, and Clara Noyes created a vision of combining public health nursing with midwifery to create a new specialty: nurse-midwifery. The concept of nurse-midwifery grew as the Federal Children’s Bureau, established in 1912 to investigate morbidity and mortality of mothers, infants, and children, suggested prenatal care provided by trained nurses could lower maternal and infant mortality rates. The Sheppard-Towner Maternity and Infancy Protection Act, passed in 1921, resulted in legislation leading to the education and regulation of nurse-midwives across the country.⁵

The profession of nurse-midwifery in Georgia officially began in 1942 with the opening of a nurse-midwife-led birthing center in Rabun County. This service expanded to include home births, hospital births, and a second birth center.⁶ Counties in which these services functioned experienced a drop in maternal mortality rates, an increase in the average number of prenatal visits, and earlier initiation of prenatal care compared to the rest of the state. However, state funding for the projects was discontinued by the early 1960s, leading to their closure and the disappearance of midwifery in the state.

Fast forward to Georgia today, where nurse-midwives are attending 15 percent of births, nearly twice the national average. To understand the success of nurse-midwifery in Georgia it is necessary to examine the work of pioneer nurse-midwives in the 1970s and 1980s who created clinical practices and education programs. These pioneers demonstrated courage, creativity, and commitment by going outside of existing norms to establish the profession of nurse-midwifery and to meet the healthcare needs of women and infants.

Elizabeth Sharp, Ph.D., CNM was a key figure in the establishment of nurse-midwifery in Georgia. In 1971, she brought faculty and students from Yale University’s midwifery education program to Grady Memorial Hospital, in Atlanta. Too many babies were being born at Grady for the obstetrical residents to manage. Sharp created a nurse-midwifery practice at Grady to care for normal, low-risk women, allowing the obstetrical residents to care for higher-risk women. Nurse-midwives and physicians worked collaboratively to care for large numbers of women receiving prenatal care and giving birth at Grady. Many of these women were uninsured or insured by Medicaid, which private physicians would not accept due to poor reimbursement rates.

Following this start at Grady Memorial Hospital in Atlanta, nurse-midwifery spread to other areas of the state where physicians struggled to keep pace with the high volume of births. Obstetricians in Americus sought Sharp’s advice as they opened the first private-practice nurse-midwifery service in 1973. The same year, nurse-midwives began working for John D. Archbold Memorial Hospital in Thomasville.

Other areas of the state, such as Dalton, Douglasville, Athens, and Austell, saw nurse-midwifery programs established by the early 1980s to provide maternity care to uninsured and underinsured women. Nurse-midwives were providing maternity care based on inter-disciplinary cooperation, continuity of care throughout pregnancy, and constant support throughout labor and birth. They provided high-quality care, achieving both patient safety and patient satisfaction. It was not long before privately-insured women began to seek out the midwifery model of care. In 1983 the first private nurse-midwifery practice in Atlanta was established at West Paces Ferry Hospital. Soon, the profession spread to physician’s offices and private hospitals throughout the city.

Entering Emory University’s nurse-midwifery education program in the late 1980s, I was taught to care for women during childbirth using a patient-centered approach to care that provides good outcomes for women and infants. Years later, during my doctoral education, I considered the best approach to researching midwifery care of women. Quantitative, statistical methods seemed inadequate to examine the empowerment of women and the safe, satisfying alternatives for maternity care provided by nurse-midwives. I realized I had been taught and mentored by the pioneer nurse-midwives responsible for establishing nurse-midwifery in Georgia. I chose to examine the economic, political, and social factors impacting nurse-midwifery by collecting the oral histories of Georgia’s pioneer nurse-midwives.

I interviewed 14 nurse-midwives that worked in clinical practice or midwifery education in Georgia during the 1970s and 1980s. Approaching my research from the standpoint of feminist philosophy encouraged a balance between the midwives’ stories and my experiences. The story I learned from these midwives was one of hardworking, committed, compassionate, scholarly women, and a few men, who went outside the medical establishment to provide access to maternity care. They provided options for women during childbirth through a unique approach to maternity care. Nurse-midwifery developed with the support of the nursing and medical professions and provided high-quality care with good outcomes.

The strength, intelligence, and fortitude of the midwives I interviewed was impressive. One of them captured this sentiment in describing her work with all “these women who were so powerful.” Georgia’s pioneer nurse-midwives were highly educated women who juggled families, personal lives, and careers as they boldly blazed trails for midwifery. They established the profession in a state where granny midwives had ushered many babies into the world and proudly bore the stigma associated with the care of poor and uninsured women. These pioneer nurse-midwives ushered the profession into the complex health care system of the twenty-first century.

Nurse-midwifery offers an alternative headline for childbearing families today. One suggestion related to How to Cut Your Odds of Having a C-Section When You Don’t Really Need One is to consider using a midwife. Public health professionals agree on the importance of midwifery care for high-quality maternity care.

Potential improvements in maternal and newborn outcomes, stillbirth, preterm birth, and unnecessary interventions have all been found to be within the scope of nurse-midwifery care. My research into the history of nurse-midwifery suggests lessons from the past can help navigate the complex waters of maternity care today. My hope for the future of nurse-midwifery was expressed by one narrator as he said:

[gblockquote]If we can get to midwifery delivering about twenty percent of the population, then it’s going to be the tipping point … that gets us on into delivering eighty percent … of the population as, as we should be. I mean … the concept of a midwife for every woman is absolutely what we’re looking at, and then sometimes they need a doctor, too.[/gblockquote]

Notes

1. Richard W. Wertz and Dorothy C. Wertz, Lying-In: A History of Childbirth in America (New Haven: Yale University Press, 1977). Return to text.
2. Laura E. Ettinger, Nurse-Midwifery: The Birth of a New American Profession (Columbus: Ohio State University Press, 2006), 4. Return to text.
3. D. C. Shelton, “Man-Midwifery History: 1730-1930,” Journal of Obstetrics & Gynaecology 32 (2012): 718-23, doi:10.3109/01443615.2012.721031. Return to text.
4. Judy B. Litoff, American Midwives: 1860 to the Present (Westport: Greenwood Press, 1978). Return to text.
5. Judith P. Rooks, Midwifery and Childbirth in America (Philadelphia: Temple University Press, 1997). Return to text.
6. Katy Dawley, “Origins of Nurse-midwifery in the United States and Its Expansion in the 1940s” Journal of Midwifery & Women’s Health 48 (2003): 86-94, doi:10.1016/ S1526-9523(03)00002-3. Return to text.