Call the Midwives—Assuming Any Are Left

In the United States, midwife-attended births are the exception, not the norm. In 2021, only 12 percent of some 3.7 million births involved a midwife. But in the United Kingdom, where nearly all planned births are attended by midwives, this norm is just the opposite.

The relative lack of midwives in the US is often cited in tandem with the nation’s higher maternal mortality rate: 30.34 per 100,000 in the US in 2021 compared to 4.5 per 100,000 in the UK. Many factors contribute to the maternal mortality in the US, the highest in the industrialized world. At 32.1 percent (about 1.2 million out of 3.7 million), the national rate of Caesarean sections in 2022 is nearly triple the ideal rate of 10 to 15 percent recommended by the World Health Organization. According to the American College of Obstetricians and Gynecologists, 40 percent of mothers in the US don’t see an obstetrician for follow-up care postpartum. Structural racism leads many mothers of color to receive substandard care, according to an article from the NIH’s National Heart, Lung, and Blood Institute, exacerbating mortality rates in minority groups. Both the Commonwealth Fund and the US Department of Health and Human Services have proposed an increase in the number of midwives as part of a potential public health initiative to address these challenges.

But why are so few midwives in the US to begin with?

The comparative difference between the two countries in the number of midwives wasn’t always so stark. Until the rise of male-led obstetrics in the nineteenth century, childbirth was typically a women-only affair, writes Nancy Schrom Dye. Around 1910, the rate of midwife-attended deliveries was the same in the UK and US, at approximately half of all births. But the declining birth-rate among the upper-class meant that increasingly such families could afford doctors rather than midwives for their deliveries. Moreover, the increasing use by physicians of “twilight anesthesia”—a combination of morphine and scopolamine—promised mothers a less painful labor than what midwives could offer. This reality challenged the practice of midwifery in both countries.

In the United States, midwives who attended expectant mothers of lesser means fell into two categories. In midwestern cities like Chicago, these attending women were largely European immigrants, writes Kate Dawley. In parts of the deep South, on the other hand, 75 percent of births among expectant women of color were delivered by apprentice-trained midwives who maintained a body of knowledge and upheld a tradition that their enslaved forbears brought with them into the US beginning in 1619. These women were referred to by institutions including the American College of Nurse-Midwives (ACNM) as “grand-midwives,” a sign of the esteem with which they were held in local communities.

Yet even then, the US grappled with one of the highest maternal mortality rates among Western nations—at 689 per 100,000 in 1920, writes medical historian Irvine Loudon. The Flexner Report on American medical education, published in 1910, called the nation’s obstetrics “the very worst showing” of any of its specialties. Although some contemporaneous studies indicate that rates of maternal mortality were not higher among women whose babies were delivered by midwives than those delivered by physicians, nevertheless, Dawley writes, leaders in the medical community often blamed lower-income midwives—many of whom were people of color—for these deaths. They used racist or xenophobic stereotypes, according to historian Judy Barrett Litoff, calling these midwives “‘evil’ and ‘inveterate quacks.’”

“[T]he Mississippi Board of Health attributed the large number of maternal deaths not to economic conditions, but to the fact that ‘a very large majority of the confinement cases among the Negroes are attended by Negro midwives, in which case little protection is afforded the patient,’” writes historian Molly Ladd-Taylor. A study of immigrant midwives in New York and Chicago called them “low-grade, ignorant, and untrained,” notes Dawley, and mistakenly identified catheters in the midwives’ bags as potential instruments of abortion. In a small town in Massachusetts, Finnish immigrant and midwife Hanna Porn was arrested multiple times and ultimately jailed in 1909 for breaking the law; midwifery had been outlawed in the state in 1907.

Writing about “the midwife problem” in a 1915 issue of the American Journal of Sociology, social reformer Grace Abbott notes that

[t]he argument against the midwife is, briefly, that she is of course not a doctor and that a well-trained doctor to attend every woman during childbirth is the ideal toward which we should direct our efforts. Any attempt to train midwives, say those holding this view, means that clinical opportunities which are needed for medical students will be given to these women.

Critics portended that not only were midwives putting mothers in danger—they were diverting lower-income patients from teaching hospitals that could train the next generation of doctors.

Immigrant women often preferred a midwife to a male doctor, Abbott writes, even when given the option of free obstetric care. She ultimately called for more centralized regulation of midwifery, given that even if prohibited, midwives would likely continue their work underground. While she acknowledges opponents who argued that the regulatory policies of Germany or Denmark might not transfer well to the United States, she writes that no one can disregard the successful beginning which has been made in England, where conditions were in many ways analogous to those in this country. In England as in the United States, many midwives who were ignorant and untrained were already practicing.

In the United Kingdom, midwives and doctors also faced tension as they competed for patients and argued over how to ensure safe deliveries. Yet, instead of steps toward midwifery’s elimination, lawmakers enacted the Midwives Act of 1902. Under this legislation, no woman could call themselves a midwife without certification. While initial requirements for such certification were loose (three months of approved training), they gradually lengthened to two years of training over the course of several years.

The act faced much opposition.

“There can be no doubt that from a medical point of view such legislation is distinctly retrograde,” opined the British Medical Journal (BMJ). “At the present time midwives are much in the same position at law as herbalists, bonesetters, and other irregular practitioners…but it has not as yet been proposed to raise their standard of education and register them as inferior orders of practitioners in their respective callings.”

In her support for the act at the Manchester Conference of Women Workers, one Rosalind Paget argued that “it was no question of doctor versus midwife, but of trained and licensed midwife versus ignorant and untrained women,” according to an account of the conference in the BMJ. By the time the law passed and was enacted in 1910, the UK entered “a new era in the history of the professional midwife.”

Writing as an American on the British law, Abbott makes the observation that it may be more difficult to enact something similar in the United States.

“The greatest obstacle to regulation is the fact that in this country the midwife is used principally by the immigrant women,” she writes, “while in England the fact that her patients were English may have influenced public opinion.”

Indeed, racial tension in the US meant that a similar attempt to address maternal health achieved a different result. With hopes of lowering maternal mortality, the 1921 Sheppard-Towner Act funded midwifery classes and regulatory programs across several state health departments, writes Ladd-Taylor. In some counties of South Carolina, for example, all midwives had to enroll in courses regardless of prior experience; if they failed to comply, writes sociologist Alicia D. Bonaparte, they risked losing their licenses. Class sessions often involved stringent inspection of the midwives’ medical bags; unsatisfactory findings could yield a six-month suspension.

Particularly in southern states, these programs often led to tension between white Sheppard-Towner nurses and midwives of color who wished to retain elements of their traditional practices.

“Working in the south during a period of white supremacy and racial tension, liberal Sheppard-Towner administrators shared the prejudices of their time,” writes Ladd-Taylor. “Perhaps partly to justify their work to southern leaders, Sheppard-Towner workers disavowed any benefits of traditional healing and, at times, even the humanity of nonwhite midwives.”

As Sheppard-Towner nurses used their legal authority to retire or revoke the licenses of midwives deemed incompetent, the number of practitioners dwindled. In one Pennsylvania county, explains Ladd-Taylor, a Sheppard-Towner agent refused to license five of six midwives. Florida claimed in 1929 that three thousand of the states’ more than four-thousand midwives had left the business due to their incapacity for instruction. In one South Carolina report, writes Bonaparte, administrators were “glad to report that the number of midwives in the State has been reduced to about 3000 from over 6000 ten years ago. This means that many of the most incompetent have been eliminated.”

Even private-led midwifery initiatives faced racial tension and faltered. In 1925, Mary Breckinridge, for example, attempted to import European-style midwifery to Kentucky via the Frontier Nursing Service (FNS), which she had founded. Historian Nancy Schrom Dye explains that the FNS provided maternity services in rural areas, relying on staff that had been trained in English lying-in hospitals. Born in Tennessee to a segregationist family, Breckinridge refused to include Black women in her midwifery program.

Ultimately, the FNS failed to secure charitable funding it needed to expand; in total, the program’s impact was “useful for poor, geographically isolated Appalachian women, but with little relevance for the nation as a whole,” writes Dye.

In 1929, Congress failed to extend the Sheppard-Towner Act, and public spending for maternal health programs decreased. With midwives waning in number, more expectant mothers sought hospital births, writes Ladd-Taylor; they saw it as a sign of social status. Women facing economic hardship amidst the Great Depression headed to public hospitals to deliver, explains Katy Dawley, the former director of midwifery in the Department of Obstetrics and Gynecology at MCP-Hahnemann University. By 1930, only 15 percent of national births were attended by a midwife.

In comparison, by 1930, midwife-led births had risen in the UK, from the aforementioned 50 percent in 1910 to 60 percent. Jean Donnison contends that, between 1910 and 1930, midwife-doctor relations in the country had eased. The National Insurance Act of 1911 increased business to general practitioners by insuring low-income workers, and World War I sent many doctors to practice on the front. With plenty of non-expectant patients in need for other treatment, general practitioners were less likely to fight for control of the childbirth “market.”

However, the UK’s maternal mortality began to rise in 1928. This trend, combined with declining birth rates and the fear of imminent war, prompted an expansion—not a restriction—of midwives’ roles in the Midwives Act of 1936. In order to deter cost-conscious mothers from seeking unlicensed, cheaper care, the law required local authorities to establish a salaried midwife service which could provide free or reduced care to the poor. By this time, practicing midwives in the UK were often trained nurses, and this act ensured their place as professionals with a guaranteed salary from the state.

“On the first day of this year the new domiciliary midwifery nursing service for London came into operation,” asserts an announcement in the BMJ. Thanks to the service, the announcement continues, “every London mother, irrespective of her financial circumstances, will now be able to call on the services of a fully qualified midwife to act either as a midwife or, if a private doctor is engaged, as a maternity nurse.” Women’s financial access both to midwifery and to specialized obstetric care increased even further with the National Health Service in 1948.

Despite the UK’s relative embrace of midwifery, challenges endure. The country is currently struggling with a shortage of midwives, and the Royal College of Midwives reported in 2021 that more than half of surveyed midwives were considering leaving the profession over concerns about understaffing and care quality. Likewise, even with a less established midwifery practice, editorials and reviews continue to push for normalizing the profession in the US. Regardless of future directions for both countries, the decisions of activists and policymakers around a century ago still reverberate in the type of healthcare mothers receive in the twenty-first century.

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