THE MIDWIFE THROUGHOUT HISTORY*

Judy Barrett Litoff, Ph.D.

ABSTRACT
This paper traces the role of the midwife in history from Biblicaltimes to the present. It
describes how a profession that was traditionally considered "women's business" was
gradually taken over predominantly by male physicians. Special attention is focused
on the decline of midwifery in England and the United States after 1600. Major factors
contributing to this decline are analyzed, culminating with an examination of the great
"midwife debate" in America in the early 20th century. The development of nurse-
midwifery after 1920 and the recent renaissance in midwifery are also briefly consid-
ered.

Midwifery has b e e n the almost exclu-
sive province of w o m e n throughout
recorded history. Several references to
the w o r k of m i d w i v e s c a n b e
found in the Bible; Exodus 1 : 1 5 - 2 2
relates the e x p e r i e n c e s of two He -
brew midwives, Shiphrah and Puah, who
refused to follow the Egyptian king's c o
m m a n d requiring that all mal e infants
b e killed. W h e n the midwives were q
u e s t i o n e d b y the king for failing to
follow his order, they replied: " . . . H e
b r e w w o m e n are not like the
Egyptian women ; for they are vigorous
and are delivered before the midwife c o
m e s to t h e m . " This passage
indicates that the pres-ence of a midwife
was considered sufficient when an
attendant at birth was necessary, an d
that parturition was believed to be such a
normal process that m a n y births went
unat-t e n d e d . ' T h e writings of
classical Greek and R o m a n
physicians, such as Hippocrates, Galen,
and Celsus, provide further information
abou t the regularity with which the
midwife
* This paper was presented at the 27th annual
meeting of the American College of Nurse-
Midwives, April 29, 1982 in Lexington,
Kentucky.
s e r v e d as the a t t e n d a n t at birth.
These writers supply evidence that m a l
e physicians w e r e s u m m o n e d only
w h e n special e m e r g e n c i e s or
difficulties arose. 2
T h r o u g h o u t th e Middle Ages ,
midwives continued to serve as at-
tendants at birth for rich and poo r alike.
Most of these w o m e n were empirics
who had familiarized them - selves with
the birth process through o b s e r v a t i
o n a n d p e r s o n a l experi - ence.
Indeed, until the 17th century, the
personal experience of childbirth was
considered one of the most es-sential
prerequisites for practicing midwifery. 3
It was during the Middle Ages that
the first regulations governing mid-
wives were enacted . These regula-tions,
which were originally adminis-tered by
the church, stipulated that midwives be
of good character, re-frain from
performing abortions, bap - tize the
infant, if necessary, and not participate
in magical rites. Ecclesias-tical
authorities were evidently par-ticularly
concerned that midwives not resort to
witchcraft and magic while performing
their services. Generally speaking, these
early church regula-tions were more
concerned with the
moral conduct of midwives than with
their technical skills.
As late as the 18th century, English
midwives were still instructed to strive
for mora l excellence . A 1724 de -
scription of th e " i d e a l " midwif e
stipulated that
SHE ought not to be too Fat or Gross,
but especially not to have thick or
fleshy Hands and ,Arms, or large-
Bon'd Wrists; which (of necessity) must
occasion racking Pains to the tender
labouring Woman . . . . SHE ought to
be Grave and Considerate, endured
with Resolution and Presence of Mind,
in order to forsee and pre-vent
ACCIDENTS. . . . SHE ought to be
Patient and Pleasant; Soft, Meek, and
Mild in her Temper, in order to
encourage and comfort the labouring
Woman. 4
On those rare occasions when the
midwife encountered a complicated case,
she was expected to recognize what was
happening and to seek the assistance of a
m o r e e x p e r i e n c e d midwife. If all
else failed, she would, as a last resort, call
upon the services of a p h y s i c i a n - s u
r g e o n . Until the 18th century, h o w e v
e r , the physi - c i a n - s u r g e o n ha d
virtually n o op - p o r t u n i t y to a t t e n
d n o r m a l births.

Journal of Nurse-Midwifery • Vol. 27, No. 6, November/December 1982 3

Copyright ©1982 by the American College of Nurse-Midwives 0091-2182/82/060003+9502.75
Knowing little about normal obstet-rics,
therefore, the surgeon would most often
be forced to use his surgi-cal skills to
save the mother at the child's expense.
Midwives also played a central role in
the birth p r o c e s s in colonial America.
One of the earliest mid-wives in the
Massachusetts Bay Col-ony was Bridget
Lee Fuller, wife of Deacon Samuel
Fuller. She traveled on the M a y f l o w e
r a n d p r o b a b l y aided in the three
births that occurred during the Atlantic
crossing. S h e continued to serve as a
midwife at Plymouth until her death in
1664. 5 Epitaphs of various other w o m e
n further attest to their value as mid-
wives. The inscription on the tomb-stone
of Ann Eliot, the wife of the Indian
missionary, John Eliot, bears testimony to
her services as a mid-wife. 6 T h e e p i t
a p h of Elizabeth Phillips, whose death
in 1761 brought an e n d to her m o r e t h
a n 4 0 - y e a r career as a New England
midwife, stated that she had " b y ye
blessing of God . . . brought into this
world a b o v e thre e t h o u s a n d
children. ''7 Perhap s the most famous
midwife of the colonial p e r i o d was A
n n e Hutchinson . Although she is most
remembered for her leading role in the
religious Antinomian controversy of the
1630s, she was also " v e r y helpful in
the times of childbirth, and other
occasions of bodily infirmities an d well
furnished with m e a n s for those
purposes. ''8
Wome n also served as midwives in
the colonies south of New England. It
was the practice of the colony of New
Amsterda m to appoin t an official " T o
w n Midwife . " In 1660, Ne w
Dr. Litoff is an Associate Professor of
History at Bryant College in Rhode
Island. She received her BA and MA
degrees from Ernory University and her
PhD from the University of Maine. She is
the author of American Midwives, 1860,
to the Present, which was published in
1978 by the Greenwood Press, Westport,
Connecticut.
4 Journal of Nurse-Midwifery • VoL 27, No. 6, November/December 1982
Amsterdam allotted this official a sal-
ary of 100 guilders per year for at-
tending the poor. In the southern
colonies it was not unusual for each
plantation to have its own midwife.
Often, she would be a slave who served
both white and black women. White
wome n also acted as midwives and
frequently were paid in kind, as was the
case of the midwife Thorpe, of Surrey
County, Virginia, who in 1685 charged a
fee of 100 pounds of tobacco for her
services, s
Most colonial midwives were held in
high esteem by the community. Those
women who were unfortunate enough to
be present at the birth of deformed or
stillborn infants, how-ever, were
sometimes suspected of practicing
witchcraft. Jane Hawkins,
a well-known midwife and friend of
Anne Hutchinson, delivered a still-born
menopausal baby described by
contemporaries as a "monstrosity." This
birth was the subject of much debate and
speculation among New Englanders, and
Joh n Winthrop de-nounced Hawkins as
"notorious for familiarity with the devil."
So much discussion followed concerning
the possibility of Hawkins' being a witch
that in 1638 the Massachusetts Mag-
istrates prohibited her from practic-ing
medicine. 9
Few rules and regulations regard-ing
the practices of midwives existed in
colonial America. This is not sur-prising
in light of the fact that all medical
practitioners -- physicians, surgeons , a p
o t h e c a r i e s , a n d mid-wives -- were
allowed to pursue their careers with
limited supervision un-til the second half
of the 18th cen-tury. Moreover , birth
was viewe d as a natural p r o c e s s in
which lit-tle specialized k n o w l e d g e
wa s re-quired. I°* Consequently, any
worn-an who had borne children and had
assisted in the deliveries of a few
* The belief that birth was a natural process
should not be misconstrued as meaning that the
colonial population correctly understood the
physiology of pregnancy or parturition. Rather,
birth was deemed natural in that it was usually
regarded in a matter-of-fact manner.
family m e m b e r s or friends coul d
rightfully be designated a midwife.
Very few of the records of colonial
and early national midwives have
survived to the present. Indeed, the
event of childbirth itself was rarely
described. Journals and diaries of
midwives are also difficult to Io-cate. n,
%
Because of the paucity of primary
sources, it is difficult to make an ac-
curate assessment about the state of
knowledge of the average colonial
American midwife. In most instances,
she provided moral support and en-
couragement to the parturient wom-an
and, otherwise, let nature work its
course. Mild herbal remedies for pain
were sometimes employed, but
midwives did not make use of blood-
letting, purging, or othe r " h e r o i c "
medical practices. This was before much
knowledge of either antisepsis or asepsis
and , thus, n o special precautions
concerning cleanliness were undertaken .
Many midwives carried collapsible
birthstools in their bags, but not every
parturient woman used the sitting
posture. Variations of the supine
position were also prac-ticed. Formal
instruction for American midwives did
not exist until the 1760s, and firsthand
experience and obser-vation furnished
the best training program for the
prospective midwife.
S o m e midwifery manuals were in
circulation, although it is impossible to
determine to what extent they were read
or how carefully the aver-age midwife
followed their instruc-tions. Seventeenth
- century midwives
i Susanna M~illerof Providence Township,
Lancaster County, Pennsylvania, kept a rec-
ord of her experiences as a midwife for the
years 1791-1815. Unfortunately, her mere-oirs
have not been published. (Susanna M£il-ler,
1756-1815: An Old German Mid-wife's Record.
Edited by M. D. Learned and C. F. Bride (n.p.,
n.d.). Located at the Library of the College of
Physicians of Philadelphia.) The diary of
Martha Moore Ballard, a midwife in Augusta,
Maine, and the surroundingtowns, during the
late 18th and early 19th centuries, is
somewhat easier to obtain. Ballard's work,
which covers the years 1785-1812 and is more
than 200 pages in length, has been re-printed.
It provides important information about the
day-to-day activities of the midwife of the late
eighteenth century. See ref. 10.
who could r e a d might have b e e n
familiar with T h o m a s R a y n o l d e '
s Byrth of Mankynde, one of the first
books in English to deal with the subject
of midwifery. It appeared in 1540 and
was a translation of a Latin work,
Eucharius Rossalin's Rosen-garten
(1514), or A Rosegarden for Pregnant
Women and Midwives. In-cluded in
Byrth of Mankynde were r e f e r e n c e
s to the birthstoo l a n d podalic version.
12
The first book written by an En-glish
midwife on midwifery was Jane Sharp's
The Midwives Book (1671). 12
Although Sharp intended her book to
serve as an instructional manual for
midwives, she w a r n e d against placing
undue emphasis on theoret-ical
knowledge. "It is not hard words that
perform the work," wrote Sharp, "as if
none understood the Art that cannot
understand the Greek. Words are but the
shell . . . . It is commend - able for men to
employ their spare time in some things of
deeper spec-ulation than is required of the
female sex; but the art of Midwifery
chiefly concerns us." 13
Probably another book of particu-lar
interest to midwives in colonial America
was a work published al-most a century
later, A Treatise on the Art of
Midwifery (1760), au-t h o r e d by the
English midwife, Elizabeth Nihell. What
distinguished this book from other
midwifery man-uals was the vehemenc e
with which Nihell attacked the growing
practice of men serving as birth
attendants.
Before the late 18th century, it was
generally d e e m e d inappropriate and
indecent for men, be they husbands,
physicians, or surgeons, to be pres-ent in
the lying-in chamber. As early as 1636, a
man in Maine was prose-cuted for acting
as a midwife.14 For man y years,
midwives' oaths had warned women not
to attend births in the presence of men
except in ex-treme circumstances. '~
Beginning aroun d the mid - 17th
century, however, the taboo against m e
n in the lying-in c h a m b e r was
gradually and hesitantly modified. The
introduction of the word "man -
Journal of Nurse-Midwifery • Vol. 27, No. 6, November/December 1982
midwife" into the English language in
the early 1600s was one indica-tion that
childbirth practices were undergoing
some significant changes at this time. 15
The man-midwife of the 17th century
was usually a sur-geon who was called
upon t ~ d e a l with preternatural labors.
Over the course of the next two
centuries, however, men - midwives
were in-creasingly engaged in routine
cases. 3,1~
The growth of man-midwifery after
1650 can be traced to a number of
complex factors. Of especial impor-
tance, however , was the gradual
evolvement of scientific obstetrics.
Probably the single most important event
which prepared the way for the
acceptance of midwifery as a science,
and, as a c o n s e q u e n c e , b r o u g h
t about the displacement of midwives,
was the development of the obstetri-cal
forceps by the British surgeon, Peter
Chamberlen, the Elder, early in the 17th
century. TM For almost 100 years, the
Chamberlens kept the for-ceps a family
secret. To ensure se-crecy, the p a r t u r i
e n t w o m a n was blindfolded, and the
forceps were carried into the lying-in
chamber in a large w o o d e n b o x c o v
e r e d with gilded carvings. Gradually,
physi-cians either bought "the secret"
from the Chamberlens or developed their
own version of the forceps. Midwives
could neither afford to buy the for-ceps
nor find physicians who would instruct
them in their proper use. ~'17
The research and writings of the
British physician William Smellie ( 1 6 9
7 - 1 7 6 3 ) played a prominent role in
popularizing the forceps and in opening
the doors of the lying-in chamber to
men. In the 1740s and 1750s, Smellie
taugh t classes in midwifery to mor e
than 900 stu-dents. Generally, he
demonstrated his procedures on
manikins, but oc-casionally he delivered
poor women in their homes at no charge
in return for his classes to observe. By
making precise measurements of the
female pelvis, Smellie was able to use
the forceps without mutilating the new-
born infant. 3,17 At about this time, the
establishment of lying-in hospitals for
the poor of London provided men-
midwives with additional o p p o r -
tunities to attend normal births.
S o m e midwives were quite out-
spoken in their opposition to having m e
n serve as attendants at birth. Elizabeth
Nihell, the renowned En-glish midwife,
angrily attacked Smel-lie a n d v e h e m
e n t l y o p p o s e d the growth of man -
midwifery . In her
1760 Treatise on the Art of Midwif-
ery, she alluded to Smellie's hand as
" t h e delicate fist of a great horse-
godmother of a he midwife." She
scoffed at
that multitude of disciples of Dr.
Smel-lie, trained up at the feet of his
artificial doll--in short, those self-
constituted men midwives made out
of broken barbers, tailors, or even
pork butchers: for I know myself one
of the last trade who, after passing his
life in stuffing sausages, is turned an
intrepid physi-cian and man
midwive.16
Despite the protestations of Nihell and
her growing number of support-ers, the
concep t of man - midwifery was
accepted by the English upper classes by
the latter half of the 18th century. 15
Meanwhile, the status of midwives
continued to decline be-cause it was
generally believed that women were
intellectually inferior to men and
therefore incapable of un-d e r s t a n d i
n g a n d p e r f o r m i n g the obstetrical
techniques that were be-ing developed.
The advances in obstetrical knowl-
edge and the increased acceptance of
men in the lying-in chamber in England
soon made an impact on midwifery
practices in the United States . S e v e r a
l p r o m i n e n t 18th - centur y
American physicians, in-cluding
William S h i p p e n , Jr., of
Philadelphia, received the MD de-gree at
the University of Edinburgh and studied
in London under disci-ples of Smellie.
Upon returning to America, these
physicians put into practice the
obstetrical knowledge that they had
learned while abroad. Unlike most of his
contemporaries, Shippen used the
information he had garnered in England
to develop a series of pioneering lectures
on mid-
5
wifery, which he offered to both me n
and w o m e n beginning in 1765. He
explained that he had planned the course
in midwifery "in order to in-struct those
w o m e n who have virtue enough to
own their ignorance and apply for
instructions, as well as those youn g
gentlemen no w e n g a g e d in the study
of that useful and necessary branch of
surgery wh o are taking pains to qualify
themselves to prac-tice in different parts
of the country with safety and advantag
e to their fellow citizens." 18 It is
impossible to es-timate how m a n y w o
m e n and men S h i p p e n trained, but
o n e medical historian has estimated
that as late as 1800, midwives who
studied under Shippen were still
practicing and that they "probably had as
good a course as was then available in
this coun - try. ''19
It was not a simple task for Ameri-can
physicians to convince colonial men and
w o m e n that they were enti-fled to
serve as attendants at birth during
ordinary labors? The devel-o p m e n t of
formal medical education in America,
however, provided po-tential men -
midwives with a decided advantage over
their female coun - terparts. By the end
of the 18th cen-tury, four medical
schools, all re-stricted to male students,
had bee n established on American soil.
2° This mean t that w o m e n were being
sys-tematically excluded from attaining
a medical education at the precise time
when knowledge of the scientific ad-
vances in obstetrics would have en-abled
them to b e c o m e more c o m p e - tent
midwives. Once this process had begun,
it b e c a m e increasingly dif-ficult for
midwives to keep up with the medical
discoveries of the 19th century, which
eventually brough t abou t the d e v e l o
p m e n t of m o d e r n obstetrics.
As the n u m b e r of men who were
trained in obstetrics increased, the n u m
b e r of parturient w o m e n wh o called
on physicians for normal de-liveries
grew as well. The challenge f r o m p h y
s i c i a n s c a u s e d colonia l American
midwives to resort quite frequently to n
e w s p a p e r advertise-ments in an
attempt to attract more
6 Journal of Nurse-Midwifery • Vol. 27, No. 6, November/December 1982
patients. Throughout the 1770s and
1780s, midwives and physicians ad-
vertised in New York newspapers in the
hope of swaying public opinion?
Competition in Boston was perhaps even
greater than in New York, and one
midwife, Mary Bass, announce d in 1772
that she was moving from Bosto n to S a
l e m b e c a u s e " m e n - midwive s are
fairly n u m e r o u s in Boston . " 21
Midwives were generally unsuc -
cessful in their c a m p a i g n against
trained physicians, and by the begin-ning
of th e 19th c e n t u r y m a n -
midwifery had b e c o m e firmly estab-
lished in America. Admittedly, mod -
esty p r e v e n t e d s o m e p a r t u r i e
n t w o m e n a n d their h u s b a n d s
from employing physicians. Of equal im-
portance was the fact that high physi-
cians' fees prohibited families with p o o
r and m o d e r a t e incomes from
engaging them. By 1800, however,
upper-class w o m e n in urban areas of
the United States regularly enlisted p h y
s i c i a n s as a c c o u c h e u r s .
3'12"22 Midwives, who had bee n denied
ac-cess to formal training, including in-
struction in anatomy , version, an d the
use of obstetrical instruments, found
themselves at a decided disad-vantage as
they tried to hold onto a profession that
had traditionally bee n defined as " w o m
e n ' s business."
Theman-midwiferydebat
e in-creased in intensity as the n u m b e
r of me n in the lying-in c h a m b e r
grew. During the first half of the 19th
cen-tury numerou s books and pamphlets
on this topic were published in both the
United States and England. Sip-
nificantly, the most vocal opponents a n
d s u p p o r t e r s of m a n - m i d w i f e
r y were physicians.
The principal argument employe d by
the opponents of man-midwifery was
that the presence of a ma n in the lying-
in chambe r offended the sense of
modesty and delicacy of the partu-rient
woman . T h o m a s Ewell, one of the
leading American physicians op-p o s e
d to m a n - m i d w i f e r y , insisted
that the male accoucheur so greatly
offended the w o m a n in the midst of
labo r that her c o n t r a c t i o n s ofte n
completely subsided. Ewell also re-
fated the case of a prominent physi-cian
who "infuriated with the sight of the w o
m a n he had just delivered, leaped into
her bed before she was restored to a
state of nature . " He further m a i n t a i
n e d that midwives could be trained to
handle normal deliveries and that they
were capable of conducting vaginal
examinations and simple forms of
version. 23
An a n o n y m o u s p a m p h l e t , p
u b - lished in 1851 and entitled An Ap -
peal to the Medical Society of Rhode
Island, in Behalf of Woman to be Re-
stored to her Natural Rights as
"Midwife" and Elevated by Educa-
tion to be the Physician of her Own
Sex, reinforced the views of Ewell.
The author argued that there was
abundan t proof that w o m e n could
serve with distinction as midwives.
Where, then, is the excuse for the in-
decencies and outrages of man-
midwifery? Why is it that, without the
plea of necessity, our wives are ex-
posed to the shame and pollution of
examinations, which are INVARI-
ABLE, and manipulations, such as a
pure-minded and sensitive woman
must blush to think of--such as must
excite the indignation of every man
who regards the person of his wife as
sacred !24
The moral emphasis of the early 19th-
century man - midwifery o p p o - nents
has caused on e historian to conclude
that they were "not moti-vated by a
desire to broade n oppor - tunities for
women, but rather by the wish to r e m o
v e fro m society the p a r a d o x created
by conflicting de-mand s of modesty and
safety. Their principal goal was to
eradicat e a practice that, to them, clearly
violated the claims of d e c e n c y a n d
de -
corum."3"*
* At least one early feminist did bemoan
the declining status of the midwife. Mary
Wollstonecraft argued in A Vindication of the
Rights of Woman (New York, 1967; reprint of
1792 edition) that women should be encour-aged
"to study the art of healing and be physi-cians as
well as nurses. And, midwifery, de-cency seems
to allot to them [women] though I am afraid the
word midwife in our diction-aries will soon give
place to accoucheur, and one proof of the former
delicacy of the sex be effaced from the
language" (pp. 221 -
222).
 Another argument employed by man-
midwifery critics in their efforts to
discredit the work of men in the lying-in
chamber was that physicians resorted too
frequently to "iron in-struments" capable
of mutilating babies and mothers. The
author of An Appeal to the Medical
Society of Rhode Island argued that
"twenty women now die in childbed, and
a hundred are tortured with instru-ments,
where there would not be one, if women,
on!y, officiated as midwives; in fact, the
very instru-ments were never invented or
re-quired until the assumption of man as
midwife . . . . " Man-midwifery critics
also accused physicians of turning to
"ergot, to stupifying chlo-roform, the
crushing forceps or the m u r d e r o u s p
e r f o r a t o r " to bring a b o u t more p r
o m p t deliveries. 24 Thus, the critics
repeatedly used the phrase, "meddlesome
midwifery" when describing the practices
of the physicians. They also charged
physi-clans with taking on normal
midwif-ery cases to build up large
medical practices.
During the first half of the 19th
century, many man-midwifery op-
ponents called for the training of
midwives. Not until Samuel Gregory
established the Boston Female Medi-cal
College in 1848 were American
midwives able to receive formal
schooling. In the mid-1840s, Greg-ory
began both writing and lecturing on the
evils of men in the lying-in chamber and
on the need to educate women in
medicine. By November 1848, he had
solicited e n o u g h money and support
to begin offering
a 3-month course of instruction in
midwifery. Twelve women attended the
first course, and between the fall of 1848
and the spring of 1851, six courses in
midwifery were offered.2s
P r o p o n e n t s of man - midwifery
harshly criticized Gregory and other
supporters of the midwife. Members of
the Boston Medical Society even
intimated that Gregory, a bachelor
without the MD degree, had a pru-rient
interest in pregnant women. The editor
of the official journal of the Boston
Medical Society charac-
Journal of Nurse-Midwifery • Vol. 27, No. 6, November/December 1982
terized Gregory's notions as "al-together
unchaste" and "calculated to beget a
prurience of thought at once at variance
with propriety, and at war with the first
principles of
v i r t u e . " 26
Man-midwifery advocates also in-
sisted that women lacked the ability to
become competent birth atten-dants.
Such remarks were directed not only
toward midwives but also toward the
growing n u m b e r of female physicians
in the United States, such as Emily
Blackwell, Har-riot K. Hunt, and Marie
Zakrzewska. In an age when domesticity
and motherhood were considered the
only proper functions of "ladies," young
women who desired careers that would
take them away from the home faced
ridicule from large seg-ments of the
population. Moreover, the established
19th-century medical view of woman
was that she was a frail creature,
dominated by her emotions. Women
allegedly lacked the intellectual capacity
to become midwives or physicians.
Many doc-tors were convinced that the
uterus and central nervous system were
closely connected . Shocks to the
nervous systems, such as prolonged or
intense study, might, in turn, pro-hibit a
woman's reproductive organs from
growing to full maturity. Physi-clans
argued that those women who dared to
engage in serious intel-lectual pursuits,
such as the study of medicine, faced the
grave risk of being unable to produce
normal, healthy children. 3'27
In an attempt to bolster their posi-tion,
man-midwifery proponents also
emphasized the potential dangers of
pregnancy. They related countless stories
of women who had died in childbirth
because the midwife waited too long in
summoning the doctor. Critics of man-
midwifery could not easily overlook this
argument since they, too, agreed that
physicians should be enlisted during
preter-natural labors. In fact, virtually
every-one assumed that the skills of the
physician were necessary during
complicated or abnormal births.
Consequently, courses in midwifery
and the diseases of women and chil-dren
were included in the curricula of the
burgeoning numbers of medical schools
established in the United States
throughout the 19th century. Although
not every medical school had a separate
chair of midwifery, the inclusion of
midwifery in the cur-ricula of medical
schools was an indi-cation of the inroads
physicians had made in a field that had
once been dominated by women.7
By the 1860s, the debate over man-
midwifery had somewhat sub-sided.
Certainly, the moral issue of whether or
not a man's presence in the lying-in
chamber was offensive no longer
elicited the v e h e m e n t emotional
response that it had during the first half
of the 19th century. Physicians had been
successful in convincing many middle-
and up-per-class Americans that the
well-being and safety of the parturient
woman were more important than
preserving decency in the lying-in
chamber. Consequently, most late 19th-
century manuals for mothers and
pregnant women were written with the
assumption that the partu-rient w o m a n
would hire both a physician and monthly
nurse for her confinement. 2s'* Male
physicians no longer found it necessary
to battle for the right to enter the lying-in
cham-ber. They had won acceptance as
accoucheurs among urban middle-and
upper-class Americans.
During the second half of the 19th
century, it appeared that the midwife was
quietly fading from the American
setting. The growth of medical pro-
fessionalism and new obstetrical dis-
coveries s e e m e d to ensure that
American midwives would eventually be
displaced by physicians. Large numbers
of Americans now sup-ported the view
that childbirth was a complicated and
dangerous proce-dure that demanded the
services of
* The monthly nurse was a w o m a n wh o was
hired to perform medical an d housewifely duties.
Her employmen t bega n at the onset of labor an d
lasted for about 1 month. She did not, however,
deliver the b a b y unless the physician was late in
arriving at the h o m e of the parturient woman .
the highly trained medical prac-
titioner. Thus, most late 19th-century
physicians, as well as most middle-and
upper-class Americans, compla-cently
ignored the midwife. Never-theless,
midwives continued to attend at least
as many births as did phy-sicians
throughout the 19th-century. As late as
1910, in fact, conserv-ative estimates
indicated that 50% of all births in the
United States were attended by
midwives, s°
Although the turn-of-the-20th-
century midwife was numerically sig-
nificant, middle- and upper-class
Americans had little first-hand con-
tact with her. They usually relied on
the services of the general prac-titioner
and monthly nurse. More-over, a
growing number of well-to-do women
were even choosing to have their
babies in hospitals, where they could
be attended by obstetrical specialists.
In contrast, immigrants, blacks, and
other poor people almost always
employed the midwife. They could not
afford to pay the high fees of
physicians, and they were opposed to
entering lying-in charities where they
were allegedly subjected to obstetrical
interference and ex-perimentation. In
addition, many immigrants and blacks
were morally opposed to having men
serve as birth attendants. Finally, poo r
people preferred the midwife, or
"granny" as she was affectionately
called, be-cause she engaged in a
variety of housewifely duties not
performed by the doctor, s°
Very few satisfactory training pro-
grams for midwives existed at the turn
of the 20th century. Most women
received their training from older
midwives or from physiclans who
awarded certificates in midwif-ery to
virtually anyone who could afford to
pay the $150 "tuition" fee.
Occasionally, physicians attempted to
establish quality schools for mid-
wives. The College of Midwifery of
New York City (1883), the Playfair
School of Midwifery in Chicago, II-
linois (1896), and the St. Louis, Mis-
8 Journal of Nurse-Midwifery • Vol. 27, No. 6, November/December 1982
souri, College of Midwifery (1895)
were three such late 19th-century
schools. For the most part, however,
the educational and training pro-grams
made available to midwives at this
time were highly inadequate.31
During the first two decades of the
20th century, however, two major
developments unfolded that caused the
medical profession, public health
officials, and lay people to begin once
again to take note of the Ameri-can
midwife. First, physicians be-came
increasingly concerned about medical
education reform and the related issue
of "overcrowding" in the profession.
Doctors maintained that
"overcrowding" had resulted in a loss
of their status and a diminution of their
income. 3~ Many physicians believed
that eliminating the midwife, or at least
substantially reducing her numbers,
would help alleviate this problem. The
second, and equally significant,
development was the rev-elation that
maternal and infant mor-tality in the
United States was alarm-ingly high.
For example, the 1910 infant mortality
rate of the United States was 124
deaths per 1000 live births. Moreover,
the Federal Child-ren's Bureau
reported in 1917 that "childbirth
caused more deaths among women 15
to 44 years old than any disease except
tuberculosis." The Bureau also
reported that only 2 of the 15 countries
it has investigated had maternal
mortality rates higher than the United
States for the period 1900 - 1910 . The
infant mortality rate of the United
States was also substan-tially higher
than that reported by some of the
major countries of Eu-rope. 33 Once
these birth and death statistics were
made public, physi-cians and health
officials began to question the
midwife's role in the birth process and
to try to determine why so many
American mothers and infants were
dying.
By 1910, physicians, and to a less-
er extent, the general public, were
embroiled in a fierce debate over the
present and future role of the mid-
wife. ~I The "midwife problem," as it
was labeled, was frequently dis-cussed
at the meetings of the various medical
societies. Numerous articles on this
topic appeared in medical journals
throughout the United States. Popular
magazines also car-ried feature stories
on the midwife. At the same time,
states began to enact new laws or to
revise already existing laws pertaining
to midwives. New York City led the
way in midwife training and control
with the estab-lishment of the
municipally spon-sored Bellevue
School for Midwives in 1911. In
addition, the United States Children's
Bureau helped states throughout the
nation to es-tablish comprehensive
midwife pro-grams. By 1924, every
state in the union had established a
Bureau of Child Hygiene, or its
equivalent. One of the concerns of
these bureaus was how to deal with the
"midwife" problem."
The height of the midwife debate
occurred between 1910 and 1920.
Physicians, many of who m were
obstetrical specialists, engineered the
anti-midwife campaign. They be-
lieved that the obstetrician would
never receive due recognition as long
as women, untrained in the medical
sciences, continued to deliver one-half
of all children born. They also argued
that childbirth was a poten-tially
dangerous and complicated condition
requiring the services of the highly
trained physician. Thus, they were
often critical of the work of gen-eral
practitioners, as well as that of
midwives. The American Association
for the Study and Prevention of In-
fant Mortality, founded in 1910,
served as a sounding board for mid-
wife opponents. Numerous papers on
the "midwife problem" and the
degraded status of obstetrics were
presented to its annual meetings.
Part of the opposition to the mid-
wife was a result of the anti-immi-
grant and anti-black prejudices of the
period. Opponents often issued
statements to this effect. Interest-
ingly, however, anti-midwife phy-
sicians did not find it necessary to
employ the often-repeated allegation
that women were biologically and
intellectually inferior to men. The
distinctions between the midwife and
the physician were clearly delineated
by the early 20th century. A woman
did not have to be a man's equal to
become a midwife. The question at
issue was not whether women were
qualified to be midwives, but wheth-er
anyone, other than the highly trained
medical practitioner, was capable of
competently practicing obstetrics.
Most of the support for the midwife
originated from public health officials
who believed that maternal and in-fant
mortality would be substantially
reduced if midwives were properly
trained and regulated. They pointed out
that the maternal and infant mortality
rates of many European countries were
well below those of the United States,
even though the per-centage of
midwife-attended births was much
higher. The country with which the
United States was most often compared
was England, whose infant and
maternal death rates had been
significantly reduced with the passage
of the 1902 Midwives Act. Proponents
also publicized the fact that those
localities in the United States, such as
New York City and New Jersey, which
had established comprehensive training
programs for midwives had also
experienced a sharp reduction in their
infant and maternal mortality rates.
By the 1920s much of the furor of
the midwife debate had tapered off.
The major reason for this change of
focus was that fewer and fewer births
were being attended by midwives.
Reports from throughout the United
States indicated that the ranks of
midwives were sharply and steadily
decreasing. By 1930, in fact, only 15%
of all births were attended by
midwives.
A variety of factors contributed to
the decline of the midwife. Certainly,
the physician's argument that obstet-
rics was a complicated medical spe-
cialty requiring the services of the
highly trained medical practitioner
played a major role in bringing about
her demise. Many people were im-
pressed with the physician's argu-ment
that maternal and infant death rates
would not be substantially re-duced
until childbirth was recognized to be a
complicated medical condi-tion. The
increased incidence of for-ceps
deliveries and cesarean sec-tions, as
well as the development of the twilight
sleep, served to bolster this position.
Furthermore, many physicians
stipulated that these new childbirth
techniques were to be performed in
hospitals. A few doctors even argued
that, ideally, all births should occur in
hospitals.
A second factor contributing to the
decline of the midwife stemmed from
the fact that midwife opponents were
better organized and more articulate
than midwife proponents. Physicians
who felt that the status of obstetrics
needed upgrading sounded forth loudly
against the midwife. They published
articles in medical journals and
popular magazines, read papers at the
annual meetings of various medical
societies, and were active members of
the American Associa-tion for the
Study and Prevention of Infant
Mortality. What began around 1910 as
an internal debate within the medical
profession over the de-graded status of
the obstetrician re-sulted 20 years later
in a full-fledged campaign to convince
the public that childbirth was an
abnormal process requiring the
services of the highly trained medical
practitioner.
By contrast, poverty, language
barriers, and geographical separation
helped to ensure that midwives would
remain isolated from each other. They
had no medium, such as the American
Association for the Study and
Prevention of Infant Mor-tality,
through which they could make their
voices heard. Some State Bureaus of
Child Hygiene helped midwives form
educational clubs and associations.
These organizations, however, yielded
very little political or professional
power. In addition,
only two journals were published ex-
pressly for American midwives dur-
ing the period 1900-1930. Both of
these journals, Topics of Interest to
Midwives, published in Chicago in
1918, and The Progressive Midwife,
a publication of the New Jersey
Bureau of Child Hygiene that first
appeared in 1927, reached only a very
small segment of the total number of
American midwives. Thus, midwives
had to depend on public health nurses,
health officials, sympathetic
physicians, and other concerned
individuals to speak out for them. At a
time when "medicine was becoming an
institutionalized, collective
occupation," midwives were forced to
go their separate
ways. 34
A third reason for the rapid decline
of the midwife was that the money
appropriated for training and regu-
latory programs was pitifully small.
Even model programs, such as
those developed in New York City,
New Jersey, and Connecticut,
suffered from a lack of funds. The
passage by the United States
Congress of the Sheppard-Towner
Maternity and Infancy Protection Act
of 1921 pro-vided additional funds
for midwife training and regulation.
Unfortu-nately, even these funds
were quite meager. Moreover, when
the act was allowed to expire in
1929, many states were forced to
curtail their
midwife activities.
The medley of regulatory legisla-
tion that was enacted between 1900
and 1930 was a fourth factor that
contributed to the midwife's down-fall.
Massachusetts was the only state to
outlaw the midwife. Other states,
however, were hopeful that she would
eventually be regulated out of
existence. Even states such as Con-
necticut and New Jersey, which were
sympathetic to the midwife's plight,
noted that their strict supervisory
programs had resulted in a reduction
of her numbers.
For the most part, however, the
laws pertaining to midwives were
quite lenient. They usually required

Journal of Nurse-Midwifery • Voi. 27, No. 6, November/December 1982 9

 that she register all births and apply
silver nitrate to the newborn infant's
eyes as an ophthalmic prophylactic.
The laws often prohibited her from
administering drugs and using in-
struments, performing vaginal exam-
inations, and attending abnormal
births. Some states, moreover, en-acted
no midwife legislation. In 1930, ten
states neither licensed nor controlled
their midwives. Six other states
required their midwives to be
registered, but not licensed. Several
states provided no penalties for vio-
fating the law, and in many areas the
laws were unenforcible. 31
Social and cultural changes, only
peripherally related to the early
2 0 t h - c e n t u r y midwife debate,
also helped to bring about the
midwife's demise. Significantly, these
changes tended to support the position
of the anti-midwife physicians. For
exam-ple, the rapid growth of
American hospitals after 1910 freed
additional beds for maternity cases. In
addition, the development of the
automobile provided pregnant women
with a relatively quick and easy mode
of transportation to the hospital. The
immigration restriction laws of the
early 1920s resulted in fewer women
demanding the services of the mid-
wife. Moreover, the United States
experienced its "first sustained de-cline
in the absolute number of annual births
. . . between 1921 and 1933. ''3s This
decline in the birth rate caused more
and more people to perceive the birth
of babies as very special events that
required the skills of the highly trained
physician.
In the midst of the early 20th-
century midwife debate, a few physi-
clans and public health advocates
began to endorse the concept of the
trained and regulated nurse-midwife as
a possible solution to the "midwife
problem." Unlike the old-style mid-
wife, who usually had no back-ground
in nursing, the nurse-mid-wife was a
qualified nurse who also had special
training in obstetrics. During the 1920s
and 1930s, the Maternity Center
Association of New York City and the
Frontier Nursing Service, a Kentucky-
based organiza-
tion, paved the way for the estab-
lishment of the first schools of nurse-
midwifery in the United States.
The number of women trained as
nurse-midwives in the 1930s was quite
small. As time progressed, ad-ditional
programs were gradually created. The
expansion of nurse-midwifery activities
throughout the United States resulted in
the forma-tion of the American College
of Nurse-Midwives (ACNM) in 1955.
Since its inception, the ACNM has
worked to improve the health of
American mothers and infants by
establishing competency standards for
midwives and attaining legal rec-
ognition for the nurse-midwife. The
utilization of nurse-midwives has time
and again resulted in improved health
care for mothers and babies. 36
Nevertheless, the concept of the nurse-
midwife has won acceptance only
slowly. Members of the medical
community and lay people fre-quently
confuse the nurse-midwife of the
present with the lay midwife of the
early 20th century. Thus, as late as
1973, less than 1% of all births in the
United States were attended by nurse-
midwives and non - nurse - midwives.
37
During the past decade, however,
the time-honored profession of mid-
wifery has experienced a renais-sance.
This renewed interest in mid-wifery
has resulted from rising medi-cal costs,
the belief that hospitals are not safe
places in which to give birth, and the
growth of the home-birth movement.
Presently, approximately 2% of all
births are attended by either certified
nurse-midwives or "inde-pendent" lay-
midwives.38 Although one of the most
striking features about childbirth in the
united States today is that it is
physician and hos-pital based, there is
every indication that the number of
midwife-attended and out-of-hospital
births will in-crease substantially over
the next 20 years.
REFERENCES
1. See also Genesis 35:17, 38:28.
2. Goodel W: When and why were
male physicians employed as ac-
couchers? Amer J Obstet Gynecol 9:
381, 1876.
3. Donegan JB: Women & Men
Midwives: Medicine, Moralityand Misog-yny
in Early America. Greenwood Press:
Westport, CT, 1978, pp. 9-37.
4. MaubrayJ: The Female
Physician. Quoted in Donegan,
Women & Men Midwives, p. 10.
5. Snapper I: Midwifery, past and
present. Bull NY Acad Med 39:503-
504, 1963.
6. Nicodemus, RE: The history of
American obstetrics. Centaur 51:26,
1945-1946.
7. Quoted in Francis R. Packard,
History of Medicine in the United
States. New York, 1931, I, p. 49.
8. Quoted in Herbert Thorns, Chap-
ters in American Obstetrics. Charles C
Thomas: Springfield, IL, 1933, p. 10.
9. Winthrop J: A Short Story of the
Rise, Reign and Ruin of the
Antinomians, Familists and Libertines
(1644), quoted in David D. Hall, ed.,
The Antinomian Controversy, 1636-
1638. Middletown, CT, 1968, p. 281.
10. See Charles E. Nash, History of
Augusta: First Settlements and Early
Days as a Town, Including the Diary
of Mrs. Martha Moore Ballard.
Augusta, ME, 1904, p. 235.
11. Scholten CM: 'On the Importance
of the Obstetrik Art': Changing customs
of childbirth in America, 1760-1825.
William and Mary Q 34:426-445, 1977.
12. Thorns H: Our Obstetric
Heritage: The Story of Safe Childbirth.
Hamden, CT, 1960, pp. 7-9, 16.
13. Sharp J: The Midwives Book.
Quoted in Donegan, Women & Men
Midwives, p. 28.
14. Hurd-Mead KC: A History of
Women in Medicine. Haddam, CT,
1938, p. 391.
15. Donnison J: Midwives and Medi-
cal Men: A History of Interprofessional
Rivalries and Women's Rights. New
York, 1977, pp. 10-11.
16. King HD: The evolution of the
male midwife, with some remarks on
the obstetrical literature of other ages.
Am J Obstet Dis Women Children
77:185, 1918; Mengert WF: The origin
of the male midwife. Ann Med Hist
4:453, 1932.
17. Graham H: Eternal Eve: The
Mys-
I0 Journal of Nurse-Midwifery • Vol. 27, No. 6, November/December 1982
reties of Birth and the Customs that Sur-
round It. London, 1960, pp. 111-112.
18. Pennsylvania Gazette, January
31, 1765. Quoted in Betsy E. Comer,
William Shippen, Jr., Pioneer in Ameri-
can Medical Education. Philadelphia,
1951, p. 103.
19. Shryock RH: Medicine in Amer-
ica: Historical Essays. Baltimore, 1966,
p. 181.
20. Shafer HB: The American
Medical Profession, 1 7 8 3 - 1 8 5 0 .
New York, 1936, pp. 13 - 19 . The four
schools were the University of
Pennsylvania Medical School (College
of Philadelphia, 1765), Columbia
University Medical School (King's
College, 1768), Harvard Medical School
(Massachusetts Medical College, 1783),
and Dartmouth Medical School (1798).
21. The Essex Gazette (Salem), July
14, 1772. Quoted in Donegan, Women
& Men Midwives, p. 122.
22. Shryock RH: Medical Licensing
in America, 1650-1965. Baltimore,
1967, p. 103.
23. Ewell T: Letters to Ladies, Detail-
ing Important Information Concerning
Themselves and Infants. Philadelphia,
1817, pp. 26, 27. Quoted in Donegan,
Women & Men Midwives, p. 177.
24. An Appeal to the Medical Society
of Rhode Island, in Behalf of Woman to
be Restored to her Natural Rights as
"Midwife" and Elevated by Education to
be the Physician of her Own Sex. Printed
for the author, 1851, p. 4.
25. The standard history of the New
England Female Medical College is
Fred-erick C. Waite, History of the New
En-gland Female Medical College, 1 8 4
8 - 1874, Boston, 1950. For a more
critical view of Gregory, see Mary Roth
Walsh, "Doctors Wanted: No Women
Need Apply," Sexual Barriers in the
Medical Profession, 1835 - 1975 , New
Haven, 1977, pp. 55 - 75 .
Journal of Nurse-Midwifery • Vol. 27, No. 6, November/December 1982
26. Boston Medical and Surgical
Journal: 37:184-185, 1847. Quoted in
Donegan, Midwives & Medical Men, p.
200.
27. Channing W: Remarks on the
Employment of Females as Practitioners
in Midwifery. Boston, 1820, pp. 4 - 7 .
Two especially useful articles on 19th-
century attitudes toward women are Bar-
bara Welter, "The cult of true wom-
anhood 1820-1860, ~' Am Q 18:151-
174, 1966; and Carroll Smith-Rosen-
berg and Charles Rosenberg, "The fe-
male animal: Medical and biological
views of woman and her role in nine-
teenth-century America," J Am Hist 60:
332-356, 1973.
28. See, for example, Pye Henry
Chavasse, Woman as a Wife and Mother,
Philadelphia, 1870, pp. 189-193; John H.
Dye, Painless Childbirth; or Healthy
Mothers and Healthy Children, Silver
Creek, NY, 1884, pp. 156-157; Anna M.
Fullerton, A Handbook of Obstetrical
Nursing for Nurses, Students and Moth-
ers. Philadelphia, 1890, pp. 6 5 - 8 2 ;
G~orge H. Napheys, The Physical Life
of Woman: Advice to the Maiden, Wife
and Mother, Philadelphia, 1890, pp. 2 4
4 - 245; Prudence B. Saur, Maternity: A
Book for Every Wife and Mother. Chi-
cago, 1891, pp. 2 1 7 - 2 1 9 ; Alice B.
Stockham, Tokology: A Book for Every
Woman, Chicago, 1885, p. 163; Tullio
Suzzara Verdi, Maternity: A Popular
Treatise for Young Wives and Mothers,
Philadelphia, 1885, p. 131.
29. Darlington T: The present status
of the midwife, Am J Obstet Dis Women
Children 63:870, 1911; Abbott G: The
midwife in Chicago, Am J Census, Statistical Abstract of the
Socio120:684, 1915.
30. Baker SJ: Discussion. Trans Am
Assoc Study Prevention Infant Mortal
3:252, 1912; Estelle B. Hunter, Infant
Mortality: Results of a Field Study in
Waterbury, Connecticut Based on Births
in One Year. United States Department
of Labor, Children's Bureau Publication,
No. 29. Washington, DC, 1918, p. 45;
"Report of the Midwife Survey in
Texas," mimeographed, Texas State
Board of Health, 1924, p. 3.
31. Litoff JB: American Midwives,
1860 to the Present. Greenwood Press:
Westport, CT, 1978, pp. 32 - 42 .
32. Burrow JG. AMA: Voice of Ameri-
can Medicine, Baltimore, 1963, pp. 5 - 10;
Gerald E. Markowitz and David Karl
Rosner, "Doctors in crisis: A study of the
use of medical education reform to
establish modem professional elitism in
medicine," Am Q 25:83-107, 1973.
33. Save the Youngest: Seven Charts
on Maternal and Infant Mortality, with
Explanatory Comment, United States
Department of Labor, Children's Bureau
Publication No. 61. Washington, DC,
1919, p. 7; Grace L. Meigs, Maternal
Mortality from All Conditions
Connected with Childbirth in the United
States and Certain Other Countries,
United States Department of Labor,
Children's Bureau Publication No. 19.
Washington, DC, 1917, pp. 7, 17.
34. Stevens R: American Medicine
and the Public Interest. New Haven,
1971, p. 145.
35. Grabill WH, Kiser CV, Whelpton
PK: The Fertility of American Women.
New York, 1958, p. 27.
36. Lang DM: The American College
of Nurse-Midwives. In: (Stewart L, Stew-
art D, eds. ) 21st Century Obstetrics Now!
Marble Hill, MO, 1977, I, pp. 89 - 104 .
37. United States Bureau of the
United States 1975. Washington, DC,
1975, p. 57.
38. Trevathan W: The independent
midwives of the 1970s. Paper presented
at the annual meeting of the American
Sociological Association, New York,
New York, August 30, 1980, p. 3.
11