The Decline in the Number of Midwife-Attended Births
Initially, in the United States, the female midwife was the primary attendant at childbirth. However, after 1750, that began to change as men came back from abroad having been trained in the “new midwifery.” From 1750 onward, the number of midwives attending births in the United States began to decline. By the 1800s, midwives ceased to attend to middle-class women in labor and more so attended to ethnic immigrants, the poor, isolated whites, and blacks. Between 1900 and 1930, the absolute number of midwives declined from 7.39 per 100,000 to 2.9 per 100,000, particularly in larger cities.a The overall percentage of births attended by midwives decreased from 50% to 12.5%.a
The number of midwife-attended births declined for five main reasons.
The first reason was the rise of doctors and the lack of support or sometimes verbal attacks from the medical community. As the number of doctors grew, they saw midwives as competition for births, possibly because midwives charged much less for services. Doctors viewed childbirth as a way to build their practice, earn fees, and achieve status, and midwives posed a threat to meeting those goals. From 1900 onward, medical journals talked about “the midwife problem.” There was very little support from medical community to raise the midwife to professional status, as Europe did. Part of this may have also been due to midwives not organizing for such changes. Midwives did not have leadership among themselves and were often geographically dispersed in the rural areas of states.
The second reason for the decline of midwives was the immutable belief in gender roles. It was assumed women could not attain mastery that was needed to perform childbirth skills once childbirth became increasingly medicalized. It was also believed that medicine did not fit with being a “true” woman and that training a woman in medicine would cause her to lose her standing as a lady and taint her moral character. In short, maleness was equated with safety, and femaleness was seen as a condition in need of male medical control.
All of this was reinforced by publications and lectures. In 1820, an anonymous pamphlet published and distributed in Boston said that women lacked the power to act that was essential to being a birth attendant. b The author believed that only men were capable of the detached concern necessary to concentrate on techniques required in birth. Doctors at the time believed that women suffered bouts of “periodical infirmity” and “temporary insanity” during menstruation that would also make them unfit to attend births. b
The third reason that midwives declined was the changing attitudes of women becoming mothers. Despite strict general roles, women were free to choose their birth attendant, and eventually, their changing tastes started to prefer doctors over midwives.
The fourth reason for the decline of midwives were the actions of local health departments. Health departments across the states decided to round up midwives, and train, register, and license them. These actions had devastating effects on midwives, particularly midwives of color, such as Southern Black midwives. Midwives were described by health officials as clumsy amateurs, ignorant, filthy, and superstitious.
Publications upheld these attitudes. As early as 1808, the Married Lady’s Companion and Poor Man’s Friend, some of America’s earliest birth manuals, denounced the ignorance of midwives and urged them to “submit to their station.” Health departments decided one solution was to train nurses to be nurse midwives, which gave rise to the nurse midwife profession, and in the 1930s, nurse midwives emerged from the traditional practice of nursing.b In 1932, the Maternity Care Association of New York began to train qualified public health nurses in midwifery.b
Finally, midwives began to decline due to the shifts in immigration. Many Immigrants who came over in the 1880s brought midwives with them. Early immigrants thought midwives were a better buy and were tired of being treated like charity cases in local hospitals. They also did not see the hospital as part of their identity, since many came from countries where the home, not the hospital, was the place for childbirth. By 1900s, in urban areas, due to ethnic migration, half of women were still being delivered by immigrant midwives.b Eventually, however, attitudes changed. Daughters of immigrants became Americanized and sought hospital births, and midwives began to disappear as second generation immigrants turned to hospitals instead of the home for their care. The number of immigrants also began to decline. In 1919, restrictions on immigration prevented new midwives from arriving to the United States.b
a. Thomasson MA, Treber J. From Home to Hospital: The Evolution of Childbirth in the United States, 1927-1940 [Internet]. National Bureau of Economic Research; 2004 Nov [cited 2016 Mar 15]. Report No.: 10873. Available from: http://www.nber.org/papers/w10873
b. Wertz RW, Wertz DC. Lying-In: A History of Childbirth in America, Expanded Edition. New Haven: Yale University Press; 1989. 302 p.
c. 09 JMGSN, 2014. Tragedies to transplants, the history of Longwood – The Boston Globe [Internet]. BostonGlobe.com. [cited 2016 Mar 15]. Available from: https://www.bostonglobe.com/lifestyle/health-wellness/2014/11/09/tragedies-transplants-history-longwood/5I7WEMXXIcxUx2BbvaoVAN/story.html
d. Brigham and Women’s Hospital: Integrated Residency Program in Obstetrics and Gynecology [Internet]. [cited 2016 Mar 15]. Available from: http://www.partnersobgynres.org/aff-bwh.asp
e. Long T. Jan. 14, 1794: First Successful Cesarean in U.S. [Internet]. WIRED. 2011 [cited 2016 Mar 16]. Available from: http://www.wired.com/2011/01/0114caesarean-first-us/