Midwifery: A History

Illysa Foster, M.Ed.

The art of midwifery has been in existence since the beginning of civilization, as women came to the aid of one another at births. Evidence of midwifery in the ancient world is apparent in myths, texts and oral traditions from many cultures and geographic areas. Until the Renaissance, there is no evidence of formal training in the field. One can argue that the art has been practiced continuously through human times, and that until the recent development of the obstetric model, birth assistance had changed little over the course of many millennia. Despite numerous pressures to end the practice of midwifery in the West, midwives have continued to practice, and we are currently witnessing a growing revival of homebirths and midwifery.

In the ancient world around the Mediterranean Sea, midwives were highly regarded in their communities. The Hebrew Bible contains a passage that confirms a high status of midwives during the exodus of the Jews from Egypt. Jewish midwives protected the sons of Jews that had been given a death warrant, yet there is no record of their punishment for disobeying the laws of Pharaoh. These brave women were known as Shifra and Puah (Exodus). Ancient Greek midwives include the mother of Socrates, Phaenarete, and Agnodike, who disguised her sex to train in obstetrics in Egypt (Rooks, 1997).

Artifacts provide us with insights into the nature of birth in the ancient world. The work of midwives is recorded on vessels found in the tombs of ancient Egyptian aristocrats in the form of hierarchical drawings (Ashford). Genesis 30:3 describes women giving birth while kneeling or on an assistant's lap. There is abundant evidence to suggest that this technique was used for thousands of years, along with early birth stools made from roughly shaped rocks among Greeks, Egyptians, Romans and Celts from 1400 BCE to 100 CE. The remnants of birthing stools suggest their use in ancient Asia, Africa, Middle East, South Pacific, and the Americas. These suggest that midwives assisted nature in birth, and that intervention was rare (Banks, 1999).

The Middle Ages saw a persecution of midwives that has been unparalleled in recorded history. The Holy Roman Empire sought to control midwives practices in Europe through rules and regulations that carried the most severe of penalties, death. Midwives were charged with the practice of witch craft for disobeying the Catholic Church doctrines. Often, midwives had to choose between their own lives or those of their clients in witch hunts that served to control the sexuality of women. As midwives cared for the dead and dying, they were often charged with murder or demonic possession when a death was not clearly explained otherwise. The vast majority of victims of the witch burnings were women, and of these many were practicing midwives (Rooks, 1997).

During the time of the Renaissance, midwives served both royalty and the impoverished. Paris became the center of birth assistance training. (Rooks, 1997). In The Rhetoric of Midwifery: Gender, Knowledge and Power (2000), Mary Lay describes the battle between British physicians and midwives over professional territory. Wise women in Britain began to write about their techniques in an effort to educate practitioners and protect their profession from regulation. In 1671, Jane Sharpe wrote the first known text written by a midwife, The Midwives Book. The text included anatomy, diagnostic tests, and herbal treatments. She argued for women's expertise in birth and advised against intervention except in extreme cases. Elizabeth Cellier proposed formal education for midwives in 1687, an expansion of their professionalism, but an end to autonomy. Sarah Stone published an instruction guide for difficult cases: Complete Practice of Midwifery. In 1760, Elizabeth Nihell argued against the instruments of interventions widely used by male practitioners (Lay, 2000).

European-trained midwives carried a tradition of woman-centered birth to the New World. Bridget Lee Fuller was a British midwife on the Mayflower who settled in Plymouth. The apprenticeship model was sole educational model at this time. Some New England midwives were executed as a result of Puritan witch hunts. In Colonial America, midwives practiced with little restrictions until the late eighteenth century (Wertz & Wertz, 1989).

The most poignant illustration of a practicing midwife in Colonial America exists in the diary of New England midwife, Martha Ballard. Ms. Ballard recorded her midwifery duties alongside her daily chores, family budgets, and child-rearing notes. An active and highly regarded citizen, Ms. Ballard was called to testify in court on a number of civil and criminal cases. Her records of vital statistics of her area are the most comprehensive of her time. She assisted at births, deaths and burials, and was treated as a peer by physicians who often consulted with her. Her midwife practice shows a large proportion of fetal demise, such as in the exerpt below:

"January 3, 1796
Rainly afternoon. I returnd from Capt Springers. Left her about house. Shee make me a present of 1/2 lb. Souchong Tea. I Came home at 11 hour. Bakt and Cleand my hous and did other matters. Was Calld at 7 hour Evening to see the wife of Eliab Shaw who was very ill when I arivd and was Delivered at 9 of a dead son. It appeared to have been dead for some tiem. The skin allmost all Came off. The mother is as Comfortable as Can be Expected. (Ulrich, 1990, p. 204)."

The invention of the forceps and other intervention tools by the Chamberlains in 1598 changed birth assistance forever. In order to preserve their place alongside the Royals as they gave birth, the Chamberlains kept secret their invention for many decades. When word of the interventions spread across Europe in the 18th century, the forceps continued to develop as male midwives usurped the business of female midwives along the upper echelon of society. Males continued to bar females from developing expertise in the techniques of obstetrics through sexual discrimination tactics at medical schools and in the field. Men who had never attended births, and did not know the process of childbirth or the art of birth assistance intervened inappropriately in labor, often causing death to mother and/or baby. By the nineteenth century, the modern obstetrics model planted itself firmly in the west as wealthier women sought the expertise of physicians over the traditional midwife (Lay, 2000; Rooks, 1997; Midwifery Info.com).

The construct of birth shifted from a natural, community-oriented to a medicalized and individualized (Lay, 2000. In this country there was nothing less than a sinister plot to undermine the integrity and reputation of midwives in order to improve the status of obstetricians in the medical field. The American Medical Association, following the leadership of Doctors Joseph DeLey and J. Whitridge Williams, systematically stripped the midwives of the U.S. of their right to practice, effectively denying American women the right to woman-centered homebirth (Rooks, 1997).

The battle over birth assistance was played out differently in Europe than in the States. British advocates for midwifery dedicated themselves to protecting the practice of midwives through licensure and regulation, as well as delineating roles to both midwives and obstetricians in the field of maternity care (Rooks, 1997).

As more and more midwives from Europe immigrated into the U.S. at the turn of the early twentieth century, a new model of nurse midwifery was crusaded by Mary Brekenridge in the Appalachian region of the South. The nurse-midwife field developed in Europe at the close of the nineteenth century, and was eventually brought to the Western Hemisphere in the early twentieth century in an effort to aid poor rural women in maternity care (Rooks, 1997). "...Mary Breckenridge founded the Frontier Nursing Service in Kentucky in 1925 amidst a long, successful medical campaign to defame and eliminate midwives" (Rooks, 1998, p.40). In 1955, the Association of Certified Nurse Midwives was founded in 1955 to add professionalism and credibility to midwifery (Davis-Floyd, 1998).

Legislation on midwifery practices and licensure varied greatly from state to state in the U.S. while traditional midwives continued to practice, many of whom originated from the African slave communities. Granny midwives continued to serve poor population in the South regardless of the legal status of midwifery. One such practitioner was Onnie Lee, the descendant of a slave who practiced in rural Alabama for over fifty years. Her services often included meal preparations, house work, and social work. She delivered babies to the disenfranchised citizens of her community with dedication, with little or no compensation. The state government revoked her license despite the necessity of her services for the poor population. As obstetricians organized to take over the practices of midwives, indigent hospitals set up maternity wards, sometimes bringing patients in by force. Without regard for patients' consent or quality of care, obstetricians practiced numerous interventions on poor women (Logan, 1989).

Traditional birth assistance was maintained in the Southwest and in Central America. Spiritual birthing-assistance techniques, such as the Mayan Abdominal Massage, and Spiritual Bathing, have been preserved in the rural areas of Central America for hundreds of years (Arvigo, 2005). Doña Irene Sotelo demonstrated a few of these at the MANA 2005 convention. By use of a rebozo, or hand-woven scarf, midwives effectively improve fetal positions in second and third trimesters. The rebozo is also used to aid in placental delivery. Likewise, in Northern Mexico and (currently) the southwestern United States, traditional healers specializing in birth, curanderas-parteras, maintain a long tradition of spiritual healing during birth assistance. By use of herbs, prayer, massage, incense, and talk-therapy, these traditional midwives have assisted thousands of births in these regions in recent history. Some states, such as New Mexico, began licensing traditional midwives (Ortiz, 2005).

Since the middle of the twentieth century, the vast majority of women give birth in hospitals with obstetricians in attendance, yet a revival of the old midwifery model was stirring in the hearts of intellectual women of the 1950s and 1960s that spurred the development of the modern homebirth movement in the U.S. "In the 1960s and 1970s many in the midwifery community thought we didn't need or want regulation," writes Barnes, a direct-entry and certified nurse-midwife (1998, p. 14).

Ina May Gaskin recorded her training and birth stories from her clients in her well-known book, Spiritual Midwifery (1973), which became a model for many pioneering midwives of the 1970s and 1980s. Accounting a piecemeal education in childbirth assistance, the author reveals a daring attempt to return the business of childbirth to women. Briefly trained on a bus outside of a university auditorium by a youthful obstetrician, Ms. Gaskin's saturation in mostly healthy birth experiences in her school bus caravan across the U.S., provided her with trust in the birth process. Her bold publication of reproductive physiology, paired with numerous accounts of successful births with minimal assistance in her community was a milestone for the modern homebirth movement. It became a source for defining the midwifery model of care (Rothman, 1998).

In recent decades, a trend of organization and licensure is apparent in the field of midwifery in the U.S. By the 1980s, direct-entry midwives had joined with nurse-midwives to form the Midwives Association of North America in 1982 (MANA). The term Midwifery Model of Care was used for the first time to describe the nature of midwives' work in homebirth. This term helped to define homebirth midwifery practice for its own philosophies and practices, rather than defining it in opposition to obstetrics (Rothman, 1998).

References
Arvigo, R. (2005). Mayan Spiritual Healing. Presented at MANA 2005 convention: Boulder, CO.

Ashford, J.I. (date unknown). Mothers & Midwives: A History of Traditional Childbirth. www.geocities.com/Wellesley/atrium/5148/hisory.html.

Banks, A.C. (1999). Birth Chairs, Midwives, and Medicine. University Press of Mississippi.
Barnes, D. (1998). Choosing Your Route. In Paths to Becoming a Midwife: Getting an Education. Midwifery Today, Inc.: Eugene, OR.

Davis-Floyd, R. (1998). The Ups, Downs and Interlinkages of Nurse-and Direct-Entry Midwifery: Status, Practice and Education. In Paths to Becoming a Midwife: Getting an Education. Midwifery Today, Inc.: Eugene, OR.

Davis-Floyd, R. (2005). Renegade Midwife: Asset or Liability? Presented at MANA 2005 convention: Boulder, CO.
Exodus 1:15 - 1:20. In The Hebrew Bible.
Genesis 30:3. In The Hebrew Bible.

Logan, O.L. (1989). Motherwit: An Alabama Midwife's Story as told to Katherine Clark. Dutton: New York, NY.
MidwiferyInfo.com (date unknown). A Short History of Midwifery. www.midwifeinfo.com/history

Ortiz, F. (2005). History of Curandera-Parteras in Northern New Mexico. Presented at MANA 2005 convention: Boulder, CO.

Rooks, J.P. (1999). Midwifery & Childbirth in America.

Rooks, J. (1998). Undecided?: Become a CNM!. In Paths to Becoming a Midwife: Getting an Education. Midwifery Today, Inc.: Eugene, OR.

Sotelo, D.I. (2005) Rebozo: Using Traditional Techniques from Mexico to Assist Babies into Optimal Position for Birth. Presented at MANA 2005 convention: Boulder, C.O.

Ulrich, L.T. (1990). The Life of Martha Ballard, Based on Her Diary 1785-1812. Vintage Books: New York, NY.

Wertz, R. & Wertz, D.C. (1989). Lying-In: A History of Childbirth in America. Yale University Press: New Haven.