Professional Documents
Culture Documents
November 6, 2010
NURSE MIDWIFERY AND BIRTHING CENTERS IN AMERICA 2
Abstract
Midwifery in the United States has undergone many transformations since Colonial times in
terms of practices and policies. Various factors influenced the formation of nurse midwifery
during the early twentieth century. Criticism by male obstetricians toward traditional midwives
threatened midwifery’s existence; however, some saw nurse midwifery as the solution to
providing maternity care to indigent populations. Eventually, nurse midwives established free-
standing birth centers as nurse midwives gained wider acceptance for providing quality, women-
centered care. Nurse midwifery has since expanded to include its own professional organizations,
and today nurse midwives practice in a variety of settings and provide care to women across the
age continuum.
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The professional identity of nurse midwifery and widespread application of birth centers
in the United States developed from multiple factors involving the changing social, cultural,
economic, and behavioral perceptions people had concerning women and childbirth. As such,
the major turning points for the history of nurse midwifery and inception of birth centers in the
United States can be illustrated by exploring the people, policies, politics, practice, and payment
methods that summarize the essential elements of midwifery history. By evaluating the
significant contributions that midwives have made, support can be gathered reflecting the
importance that midwifery places in providing excellent maternal and fetal outcomes.
Midwifery
Since ancient times, the practice of midwifery has been empirically passed from woman
to woman; furthermore, few cultures involved male participation during childbirth (Munro &
Spiby, 2010, pp. 57–58). Eventually, midwifery laws, regulations, and educational programs
were developed in Europe and Britain during the middle ages, and Germany passed one of the
first laws regarding midwifery as a profession in 1492 (Rooks, 1997, p. 12). In France,
municipal regulation of midwives required witnesses to attest to the midwife’s moral character,
and an examination of skills had to be passed. However, most midwives were illiterate, older,
and multiparous; they possessed limited knowledge of anatomy and physiology and were
motivated by earning additional income for their families (Kalisch, Kalisch, & Scobey, 2004, p.
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393). By the 1600s, the social status of midwives improved, and midwifery education expanded
due to the work and writing of Louyse Bourgeois, a Parisian midwife (Rooks, 1997, p. 15).
Midwifery practices used by early American settlers were influenced by the birthing
traditions of European and African immigrants (Rooks, 1997, p. 18). As in Europe, childbirth
was primarily a female event that occurred in the home (Ettinger, 2006, p. 6). Midwives focused
on providing emotional support for the laboring woman and intervened occasionally by
employing turning techniques and administering liquor for pain relief. After the birth, the
midwife stayed in the home to ensure the wellbeing of the woman and baby and assist in some of
the basic household chores. Midwifery training mainly consisted of unregulated apprenticeships
resulting in unequally skilled practitioners, and most midwives did not consider themselves
members of a profession. Payment also varied for the services provided by midwives and ranged
from a monetary reward to cheese or bolts of cloth (Mays, 2004; Rooks, 1997).
By the late 18th century, male physicians (who were predominately Caucasian and
midwives (Ettinger, 2006, pp. 6–7). There were multiple factors that attracted birthing women to
choose male physicians: Women desired forceps, bloodletting, and anesthetics that could
potentially save lives and increase comfort; women assumed that physicians possessed more
advanced training in anatomy and physiology than midwives; women assumed that interventions
by physicians during the childbirth process are necessary; and women believed that the male sex
held more prestige over the female sex (p. 7). In the 1920s, these man-midwives or modern-day
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obstetricians challenged birth as a natural process and promoted the movement of birth from the
home to the hospital so that birth could be managed through medical procedures such as
episiotomies and labor inductions (p. 8). As women increasingly desired the predictability, pain
management, and technology that institutions offered, hospital-based births under the guidance
The campaign against midwifery coined the “midwifery debate” began in the early 20th
century (Rooks, 1997, p. 24). Physicians viewed midwives as being “hopelessly dirty, ignorant,
and incompetent” and blamed midwives for contributing to puerperal sepsis and neonatal
opthalmia (Ehrenreich & English, 1993, p. 32). Although the Flexner report of 1910 criticized
the state of medical education by illuminating the fact that many graduating physicians had never
attended a birth during their academic career, physicians argued that midwifery should be
eliminated and medical training in obstetrics bolstered (Kahn, 1995, p. 192). This was partly due
to the fact that physicians desired to gain from the lucrative business that midwives had, and
physicians ignored the fact that physicians did not provide better outcomes than midwives
(Ehrenreich & English, 1993; Stewart, 1998; Rooks, 1997). Additionally, the Flexner report
deemed medicine not practiced under a license illegal, and childbirth became viewed as
dangerous, requiring the assistance of physicians (Rooks, 1997, p. 24). Facing almost certain
abolishment, midwives chose to join with the already-established profession of nursing to form
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Public health concerns promulgated the need for nurses with advanced training in
obstetrical care and provided an opportunity for the burgeoning field of nurse midwifery to
expand. The Children’s Bureau conducted research in the early 1900s to gain information about
maternal and child healthcare in the United States. The studies drew attention to the high infant
and maternal mortality rates, compared to Western Europe, which resulted in an increased
interest in promoting prenatal care in the United States (Rooks, 1997, p. 35). In response, the
Maternity Center Association (MCA) addressed the prenatal care needs of women in New York
City by opening one of the first nurse-midwifery programs in the United States, The Lobenstine
In rural Kentucky, Mary Breckinridge proved that nurse midwives could provide
adequate maternity care to women and support the general health needs of the family. She
established the Frontier Nursing Service (FNS), which initially employed British nurse
midwives. The service was set in the Appalachians, a terrain that was so difficult to maneuver
and possessing so many poverty-stricken people that she hoped it would demonstrate that this
type of nursing and maternity care could be duplicated all over the country with less effort
(Breckinridge, 1981, pp. 157–158). Nursing posts were set up over the county, and the nurse
midwives provided home visits for prenatal care and general health complaints. Nurses rode on
horseback to patients’ homes with saddlebags full of medical supplies. Donations from wealthy
families, including the Ford family, contributed in sustaining the service (p. 195). Louis Dublin,
an employee of the Metropolitan Life Insurance Company, studied the first 1,000 deliveries of
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the FNS and found that the lives would be saved if the FNS model were implemented on a larger
scale (p. 312). When Breckinridge’s nurse midwives left the United States during World War II,
Breckinridge established her own school of nurse midwives. The legacy of Breckinridge’s desire
to increase the wellbeing of families persists today as the Frontier School of Midwifery and
Family Nursing has a student body representing all 50 states and multiple countries (Rooks,
Although nurse midwives were gaining a stronger presence in the public health arena,
they still lacked a professional organization to set policies. In 1944, the National Organization of
Public Health Nursing (NOPHN) created a nurse midwifery branch and collected data on current
nurse midwives practicing in the United States (Rooks, 1997, p. 41). When the NOPHN ended
in 1952, nurse midwives tried to find their place among the American Nurses Association (ANA)
and the National League for Nursing (NLN). As a result, nurse midwives who met at the ANA
convention in 1954 decided to form the American College of Nurse Midwifery. Finally, in 1968,
the American College of Nurse Midwifery merged with the American Association of Nurse
Midwives (AANM) to form the American College of Nurse-Midwives (Ettinger, 2006, p. 184).
Birth Centers
The American Public Health Association (APHA) defined a birth center as a health
facility not associated with a hospital where mothers who experience uncomplicated pregnancies
can give birth (1982, para. 5). In 1945, the first birth center, “La Casita,” was created in rural
New Mexico as a place where women who lived too far from the hospital could come to give
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birth (Rooks, 1997, p. 74). Following suit, the MCA established its own freestanding birth
center in Manhattan due to increased rates of dissatisfaction with hospital birth and increased
rates of unsupervised home births in urban areas in 1975. Lubic concluded that “out-of-hospital
birth can be safely managed, providing there is professional supervision of a carefully screened
population” (as cited in Rooks, 2007, p. 74). Thereby, the MCA’s Childbearing Center became
an avenue for nurse-midwives to provide the basic tenets of the birth center concept by giving
quality, inexpensive care to low-risk women by focusing on prevention and early detection of
centers has seen many changes. In 1979, the APHA began endorsing birth centers as an
alternative to hospital births for normal pregnancies (1982, p. 1). As such, it set forth guidelines
for the licensing and regulation of birth centers for state and local health agencies to consult.
These guidelines included the appropriate measures that birth centers should take to provide
maternity care through specific staffing, facility, services, policies, and procedures (pp. 1–7). The
chief policies regarding the welfare of pregnant women included the staffing of licensed birth
support, serving only women who have uncomplicated pregnancies, possession of limited
surgical services, maintenance of careful records of care, and consultation agreements with
obstetrical physicians. By 1988, the Civilian Health and Medical Program of the Uniformed
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Services (CHAMPUS) deemed that birth centers must be accredited, and rules were published
concerning payment methods (Ernst, 1994, p. 132). Currently, birth centers receive most of their
payment by contracting with major health insurance companies such as Aetna, Humana, and
As more women chose birth centers over acute care hospitals, many desired verification
that birth centers could provide safe care (Ernst, 1994, pp. 132–133). In response, a cohort of
11,814 women were admitted to birth centers for treatment during labor that included the
continuous attendance of a nurse midwife, occasional use of tub hydrotherapy, and minimally
invasive procedures. Of these women, there were no maternal fatalities and minimal neonatal
mortalities. The “National Birth Center Study” suggested that birth centers provide safety,
satisfaction, and savings comparable to other birth settings (Rooks et al., 1989). Additionally, the
“National Birth Center Study” suggested that birth centers could assist in appropriately
identifying women who are at a low risk for complications during labor and delivery (Ernst,
1994, p. 133).
In order to champion family-centered births, the MCA became the American Association
of Birth Centers (AABC) became the primary nonprofit organization for promoting national
accreditation, state regulation, research, and quality services for birth centers (AABC, para. 1).
The AABC is currently lobbying, collaborating with other organizations, and promoting birth
research in order to address the different threats to the sustainability of birth centers, which
include exorbitant malpractice insurance rates, the lack of a federally mandated facility fee, and
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insufficient reimbursement for the services that nurse midwives provide (Phillippi, Alliman, &
Midwifery in the United States has grown and developed over time and continues to be
affected by the varying people, political systems, health policies, and payment methods that
make up the American health care system. This is reflective in the way nurse-midwives have
incorporated a wider range of age groups outside of the maternity cycle. The practice of nurse-
midwives now includes adolescents seeking maternity and gynecological care to women who are
perimenopausal and women who have reached menopause (Barger, 2005, para. 7). Likewise,
family planning was added to nurse-midwifery practice after 1965 when the government began
to support initiatives to limit unwanted births (Stone, 2000, p. 10). With the increased use of
technology and blurring between uncomplicated and complicated pregnancies, some nurse
midwives collaborate with physicians in the clinic setting to provide comprehensive care across
the continuum (p. 14). The expansion of nurse midwifery practice to the hospital setting during
the 1950s and 1960s allowed nurse midwives to increase their scope of practice to include
greater technical skills such as episiotomies, intravenous solution, and use of fetal monitors (p.
10). Thus, midwives are not confined entirely to the home environment and birth centers as their
only settings for assisting in deliveries. Ultimately, nurse midwives represent skillful
professionals who have adapted themselves to the differing needs of the women and families
they serve.
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References
AABC. (2010). Will my insurance pay? American Association of Birth Centers. Retrieved
American Public Health Association. (1982). Guidelines for Licensing and Regulating Birth
Centers. American Journal of Public Health, 73(3). Retrieved November 4, 2010, from
http://www.birthcenters.org/open-abc/bc-regs.php
Barger, M. (2005). Midwifery practice: Where have we been and where are we going? Journal
of
Ehrenreich, B. & English, D. (1993). Witches, midwives, and nurses: A history of women
Ernst, K. (1994). Health care reform as an ongoing process. Journal of Obstetric, Gynecologic,
https://angel.frontierschool.edu/AngelUploads/Content/2010-Fall-NM601-1-
Institution/ErnstHealth.pdf
Ettinger, L. E. (2006). Nurse midwifery: The birth of a new American profession. Columbus,
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Kahn, R. P. (1995). Bearing meaning: The language of birth. Illinois: University of Illinois.
Kalisch, B. J., Kalisch, P. A., & Scobey, M. (2004). Emergence of modern midwifery. In
Teijlingen, Lowis, McCaffery, & Porter (Eds.), Midwifery and the medicalization of
Mays, D. A. (2004). Women in early America: Struggle, survival, and freedom in a new world.
Munro, J., & Spiby, H. (2010). Evidence-based midwifery: Applications in context. Oxford:
Wiley-Blackwell.
Phillippi, J., Alliman, J. & Bauer, K. (2009). The American association of birth centers: History,
membership, and current initiatives. Journal of Midwifery & Women’s Health, 54(5),
387. doi:10.1016/j.jmwh.2008.12.009.
Rooks, J. P. (1997). Midwifery and childbirth in America. Philadelphia, PA: Temple University
Press.
Rooks, J. P., Weatherby, N.L., Ernst, E.K., Stapleton, S., Rosen, D., & Rosenfield, A. (1989).
Outcomes of care in birth centers: The national birth center study. New England Journal
Stewart, David. (1998). Five standards for safe childbearing. Marble Hill, MO: Quality Books.
Stone, S. (2000). The evolving scope of nurse-midwifery practice in the United States. Journal
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