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Final Paper: The History of the Midwife

Julie Kotlowski
Modern History
The History of the Midwife
There are Biblical references to Midwives dating back to as early as
2000 BC. Throughout history, midwives as independent practitioners are
identified as the guardians of normal childbirth. Their knowledge of
women’s health has been seen as mystical, having power over nature and
concerned with matters not understood by men.

According to The Encyclopedia Britannica, “The profession of midwife
must be one of the oldest, being clearly recognized in the earliest books
of the Old Testament and an accepted element in the social structure in
ancient Greece and Rome.” 1 The word midwife is from the Anglo-Saxon “mit
wif” or “with woman”. The ancient called her the wise woman – as she is
known in France (sage-femme) and Germany (weise frau). 2
Midwives in the Bible
Biblical references to the practice of midwifery date back nearly
four thousand years. It is mentioned in Genesis 35:17, which may be dated
around 1890 BC. This verse states, “And when she was in hard labor, the
midwife said to her “Fear not, for now you will have another son.”” 3
Biblical recognition of the functions of midwives included several
verses recounting the experiences of two Hebrew midwives who refused to
kill male infants in defiance of the King of Egypt (Exodus 1 :15 – 22).

Other verses in the Bible also make passing references to midwifery
attendance at birth, implying that it was ubiquitous (Genesis 35:17;
38:28).


Midwives in Ancient Times
[pic]
Ancient Egyptian women are assisting a woman giving birth. Since time began
women have assisted each other to give birth. This is actually a ‘relief’
sculpture of Cleopatra in the classic upright posture for birth. The woman
to the far right is holding a pair of “ankhs” which is the symbolism for
“life”. The midwife has outstretched arms to receive the baby. 4
In Greek, Roman and Egyptian times, midwives functioned as respected,
autonomous care providers to women during their reproductive cycles
although they were not always called “midwife” per-say. A midwife could be
a friend, family member or neighbor. They learned the trade through
apprenticeships where the knowledge was passed down from family member to
family member or from friend to friend. The work of the midwife included
providing emotional support, encouragement, medical care, and religious
help and protection to women during their lives. The areas that midwives
focused on were pregnancy, labor, fertility, and contraception.

Since birth and delivery could be dangerous for both the mother and
child, ancient Egyptian midwives used many goddesses and gods for help and
protection. Goddesses and gods which ancient Egyptian midwives and women
thought would help during pregnancy and birth were Hathor, Bes, Taweret,
Meskhenet, Khnum, Thoth, and Amun. 5
Soranus’ writings from the 2nd century AD provide us with proof of
midwifery in Ancient Rome. Soranus was a physician himself and defined a
set of guidelines for becoming a suitable midwife. He mentioned that it
took an advanced and able-bodied woman to become a midwife and that to
become a “suitable midwife,” one must be “literate, with her wits about
her, possessed of a good memory, loving work, respectable and generally not
unduly handicapped as regards her senses…robust, and, according to some
people, endowed with long slim fingers and short nails at her fingertips.”
6
In some cases Ancient Roman midwives, enjoyed the same wealth
and status as their male counterparts. Some women were paid very highly
for their role in the birthing process, while other midwives only took a
small amount of money form women who could not afford to pay for a more
experienced midwife.

There are early references to midwifery dealing with first century
Rome. Will Curant, discussing the state of medical practice during Rome’s
“Silver Age” (AD 14-117), states that Quacks continued, but sound practice
increased. Midwives saw most Romans into the world, but many of these
women were well trained. 7
[pic]
This ancient Greek sculpture depicts one of our Greek ancestors in the act
of squatting upon a birth stool. Notice the midwife is depicted with hands
ready to catch the baby who is just beginning to crown. 8
Midwifery in the Dark and Middle Ages
Throughout the dark ages there were only a few qualified “Doctors”.

Most of care was provided by midwives, barbers, and lay clergy. All
written history leads us to presume that obstetrics during this time was a
matter for the midwife, and no doubt, free of the possibilities of
infection found in a large hospital.

In their practices, midwives routinely used herbs and potions, as
opposed to the general use of pharmaceuticals we see today. The midwives
of these centuries generally continued to learn by the apprentice model.

As an apprentice, skills and knowledge were shared from generation to
generation.

This was also the time when midwifery was viewed as witch-craft due
to the use of natural healing they depended on. Many women healers were
being hung. This was also a time when superstitions became part of the
laboring woman’s birth experience. Some women were whipped to induce
labor. There is also a tale of a mediaeval German Empress in whose labor
room 20 men were whipped, two to death. 9
Midwifery in Early Western Europe
By the 1600s and 1700s midwives in Western Europe could be divided
into 2 main groups: “urban” and “traditional” midwives. 10 Urban midwives
were highly qualified and supervised by professionals. Traditional
midwives practiced in rural towns and villages without training or
supervision. The urban midwives before 1750 or so were probably better
than the doctors and represented the best practice of the time in terms of
the knowledge then available.

Some midwives in the 17th century were licensed by the Bishop’s
Court, and had to produce letters of reference of good character from
clients in order to practice. The bishops desired to prevent witchcraft
associated with birth and to ensure that midwives were loyal to decrees of
the church and state regarding birth, since they were allowed to baptize
infants in emergency situations. The bishops required they receive an
Episcopal license, which prohibited her from coercing fees, giving
abortifacients, practicing magic, or concealing information about birth
events or parentages form civil or religious authorities. The license also
prohibited her from refusing to attend to poor women. 11
Male midwifery before 1750 was most frequently associated with
attendance at emergencies. Between 1750 and 1875 men-midwives and medical
doctors managed to erode the public confidence in the midwife’s abilities.

Medical doctors gradually extended their control from coping with difficult
births to managing pregnancy generally as part of an enlarged role in the
normal care of the patient. Two forms of technology: the speculum and the
forceps introduced during this time enabled doctors to alter the dynamics
of the previously female only domain of childbirth.


Midwifery in Early America
[pic]
Here a farmer’s wife gives birth at home in rural Ohio. This is a drawing
by George Engelmann around 1882. 12
In the U.S., midwives, like physicians, practiced without specific
education, standards, or regulations until the early part of the 20th
century. The early settlers to America brought with them their customs and
practices which included those pertaining to childbirth. The long-standing
rituals in birth included female friends and relatives who “came to the
expectant woman to provide comfort and practical aid.” 13
The importance of midwives was shown in the fact that in some New
England towns they were provided with a house or lot rent-free with the
condition that she always be ready to attend to those that need her service
and never refuse to go. Non-English colonies often kept midwives on the
colonial payroll. The Dutch West India company salaried midwives and gave
others free houses in the city on the explicit condition that they attend
to the poor when needed. In the south slaves usually played the role of
the midwife, attending to both white and black births on plantations.

“Before and during the Colonial period English society did not
consider midwives to be part of the medical establishment or
professions but saw them as performing a special social and quasi-
religious function. That is, midwives did not formally train for their
work, did not organize a guild to license midwives, and did not
transmit skills by formal apprenticeships. Rather, midwives succeeded
one another by selecting themselves, or being selected by other women
to attend births.”14
The colonies followed the European influence of licensing midwives.

In the colonies where Anglican influence was prominent, such as New York
and Virginia, civil licensing of midwives was required.

Although detailed statistics are lacking, the evidence available from
this time shows that midwives’ patients were less likely than physicians’
patients to die of childbed fever or puerperal infection, the most
significant cause of maternal morbidity and mortality at this time.

There were a few notable midwives who carved their names in early
American history. One notable midwife was a healer named Martha Ballard.

Ballard practiced in Maine between 1785 and 1812. She kept a diary of her
life and work. Laurel Thatcher Ulrich later wrote a portrait of Martha
Ballard’s life and work, A Midwife’s Tale, published in 1990. This book
won the Pulitzer Prize and was made into a film. 15
A few other recognized midwifes of this time include, Mrs. Rebecca
Fuller, the wife of Dr. Samuel Fuller. She practiced in Boston from 1630
to 1663.

Ruth Barnaby delivered babies for 40 years and she began at the age of 60.

Elizabeth Phillips, also from Boston delivered more than 3000 babies
according to her tombstone. She practiced from between the years 1719 and
1759.


[pic]
This Pennsylvanian pioneer wife reclines upon her husband for support while
the midwife catches the baby. Note the upright position and the women who
attend her. 16
Transition to Medical Births
Medical historians call have called the years before 1750 “the age
of the midwife” for doctors were few and far between when it came to
dealing with birth.

It was really the mid-nineteenth century when doctors began to enter the
birthplace. Midwives did not exactly welcome these new, so-called experts.

The birthplace belonged to them, in their eyes.

These early ‘obstetricians’, if you will, were often men who’d taken
a few weeks off from forge or farm to attend an unaccredited school where
they read textbooks and listened to lectures form others who were hardly
better educated than they. During this “training”, it was morally
unthinkable for them to witness an actual birth. The midwives, in
contrast, had been learning their trade since childhood. They knew a
considerable amount more than the doctors, including their limits.

The attitude towards birth was shifting to being viewed as a medical
problem that should be handled by physicians. In the 1800’s many women
died in childbirth. At the time all the causes were not understood.

Babies got stuck in their mother’s pelvis, which might have been distorted
by inadequate diets. Rachitic pelvis, as this was called, was remedied by
dismembering the infant in utero and removing it in pieces. Mothers also
died from complications of tuberculosis which, in the nineteenth century ,
was an epidemic. Poor urban women died because their bodies were
compromised by unclean water and milk, poor diet, and overwork. Rich women
faltered because they subsisted on fashionable proteinless diets and
because they wore corsets that grievously distorted their reproductive
anatomy. All classes of women died from postpartum infection called
childbed fever. 17
Doctors, with their many devices and drugs, promised to shorten labor
and reduce pain. Physicians declared themselves to be the proper
caregivers for childbearing women, and the hospital was deemed to be the
proper setting for that care. According to one of the foremost authorities
of the day, Dr. Joseph DeLee, birth was a dangerous process from which few
women escaped unscathed, and proper management of this pathological
condition required a program of routine medical intervention.

Doctors continued to find more and more reasons to intervene in the
childbirth process. For the most part, American women accepted t eh
intervention and progressive control of the medical profession. In 1900,
midwives attended almost half of all births; by 1935, the number had
decreased to 12.5%. 18 Midwives were seen as dirty, illiterate, and
ignorant, and women were convinced that they were safer in the hands of
doctors and hospitals.

Medical journals began to address the “midwife problem”. The
historian Frances Korbin has divided the discussants of the ‘problem’ into
four groups: (1) advocates of immediate abolition of midwives, with legal
prosecution of any who continued practice; (2) those who believed in
eventual abolition, with careful regulation of existing midwives until
enough doctors could be educated to take their places; (3) those who wished
to educate the midwife until she reached the status of English and European
midwives; and (4) those (mostly Southerners) who believed that, if midwives
could be trained to wash their hands and to use silver nitrate drops, no
more could be expected. The one thing most discussants agreed upon was that
the worst birth attendants were not midwives but the general practitioners
who tended to intervene needlessly in normal births. 19
Emergence of the Nurse-Midwife
During the midwives darkest hour, the seeds of the future of
midwifery were being sowed. Perhaps as a surprise, what the medical
profession first promised (a safer and easier childbirth) was being found
by many women in a return to the “old ways” and trusting more in nature and
way our bodies were intended to give birth.

Public Health Nurses in New York City in the 1920s acquired
additional training in midwifery to provide maternity services to women who
were being ignored by the physicians and receiving inadequate maternity
care. They called themselves nurse-midwives.

A notable woman on the frontier of nurse-midwifery was Mary
Breckenridge. Breckenridge introduced modern nurse-midwifery based on the
British model, into the United States. In 1925 she established the
Frontier Nursing Service as a demonstration project of complete family
health care in a remote rural area, and directed it until her death in
1965. 20
[pic]
Mary Breckenridge
After Dr. Delee’s slander campaign against the midwives and his successful
campaign to scare our grandmothers to the hospital so that resident
physicians might learn and have women to experiment upon during birth, Mary
Breckenridge became the first American nurse midwife. She rode on horseback
; delivered over 1000 babies in rural Kentucky. She founded The Frontier
Nursing Service to provide isolated families with health care. There were
no maternal deaths due to labor despite the fact these women lived in the
Appalachian mountains and the nurse midwives delivered these women in their
own home!
What is more amazing regarding this statistic is that if you delivered in
the hospital at that time, maternal mortality was about 50 per 1000 women.

21
Although home birth had been the norm in the early days, nurse-
midwives gradually moved almost completely into hospital settings, usually
relinquishing control and autonomy over their practice to physicians and
adopting some of the interventive procedures used by them.

Nurse-midwifery practices have grown rapidly during the 1980s and
1990s assuming a large part of the care of underserved and vulnerable women
from isolated rural and impoverished inner-city areas. They are also
emerging as the care-giver of choice for women of all socio-economic
classes. This may be due to the comfort of care our ancestors sought from
a woman to woman relationship.

At the present time, there is no doubt that midwives offer women
safe, effective care with good outcomes. Midwives abide by their namesake,
“with women”. They listen to women, talk with women, and stay with women.

Every year, more American babies are born into the hands of midwives. In
some states this is as high as 20% of all births. Midwives believe they
can enhance the experience of pregnancy and birth for women. Being a
patient of a midwife at the present time, I can contest that this is the
absolute truth.


Bibliography
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tm
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A History of Midwifery in Pictures