Friday, October 24, 2008

"A Brief History of Midwifery in America," or, "Why on Earth Are There So Many Kinds of Midwives?"

I've been wanting to write an article on this subject for a long time, but didn't have time to do the research - and then I found a book which had done that research for me! Thus, most of the information for this article is taken from "Mainstreaming Midwives: The Politics of Change," edited by Robbie Davis-Floyd and Christine Barbara Johnson. I will be reviewing this book (in glowing terms!) very soon as well, but I wanted to write this article as soon as I could, as I need to return the book to my midwife on Sunday. So here goes!

Midwives are still, for the most part, America's best-kept secret in terms of health-care practitioners. When I was in Border's last year buying a copy of Elizabeth Davis' "Heart and Hands," the clerk said, "Do midwives even still exist? You're kidding!" Yes, Virginia, there really are midwives! Alive and thriving (and growing!) but unfortunately still attending only about 1% of all births.

However, for those of us who do know about midwives, the sheer number of midwife "titles" can be overwhelming and confusing - certified nurse midwife, certified midwife, certified professional midwife, lay midwife, licensed midwife - and more!

The purpose of this article will be to briefly (and incompletely, I'm afraid) examine the history of American midwifery and throw some light onto the differentiations between types of American midwives.

The history of American midwifery is a long and conflicted story which has unfortunately not always been a positive one. The story of midwives in the early part of the 20th century was marked by persecution and witch-hunts (still going on, unfortunately), and in the latter part of the century was marked with internal strife and divisions which led to midwives oftentimes fighting amongst themselves over ideological differences rather than uniting as a common front.

To begin....

In 1900, only 1% of births took place in hospitals. By 2000, those numbers had reversed, with only 1% of births taking place at home. How and why did this change occur? It occurred because a decision was made by the medical profession that birth was profitable and midwives, therefore, needed to go. A massive propaganda campaign was launched against midwives, with midwives portrayed as dirty, ignorant, old-fashioned, archaic, disease-carrying crones who were unsafe care-givers and who were practicing medicine illegally. This campaign was especially effective with immigrant mothers, who wanted to forsake everything having to do with the Old World and become as "American" as possible - and being "American" soon came to mean having a male obstetrician delivering one's babies in a hospital (and giving formula, etc.).

Unlike European midwives, who were well-organized in trade unions and professional organizations and were able to protect themselves and their profession, American midwives were not well-organized, or even organized at all. They were isolated, working within their own ethnic groups, with little to no communication with other midwives, and had no professional organizations. To put it vulgarly, they were sitting ducks who went down with one shot - they were not able to resist the combined efforts of the government and the medical establishment who were bent on eradicating them.

Of course, lay homebirth midwives never completely disappeared - but their numbers were greatly reduced and they were forced to practice underground.

Midwives who wished to continue practicing legally made a monumental decision, one that affects American midwifery to this day - they decided to unite with the respected position of nursing. Thus, in 1925 Mary Breckenridge formed the first organization uniting nursing and midwifery, the Frontier Nursing Service, bringing midwifery care to the Appalachian poor, and the profession of nurse-midwifery (eventually producing the certified nurse-midwife) was born.

In 1930 a second nurse-midwifery institution was opened - the Lobenstine Clinic in New York City, later home of the nation's first nurse-midwifery program. This clinic met the needs of poor, inner-city women and was staffed by nurse-midwives.

Initial efforts of nurse-midwives met with success. There was a notable lack of opposition from obstetricians because of the clientele that the midwives were serving - most obstetricians did not want the "down and dirty" jobs of providing care to the poorest-of-the-poor or to mothers in extreme rural districts. Midwifery survived by meeting needs no one else wanted to meet, and by finding a niche for itself there. Nurse-midwives also survived by proving their worth with excellent statistical results and by finding small numbers of physicians sympathetic to their cause who would support them and work with them.

Thus, nurse-midwifery gained a foot-hold in American maternity care, but growth for the profession was extremely slow. Additionally, many of America's nurse-midwives were lost to the system in that they decided to pursue careers overseas in missions work or left the nurse-midwifery profession altogether and worked in health-related fields.

Also, at this time nurse-midwifery was not synonymous with hospital birth, as it often is today - many nurse-midwives attended home births or worked in maternity centers. Thus hospital births were attended primarily by obstetricians.

In 1929, six nurse-midwives from the Frontier Nursing Service formed the American Association of Nurse-Midwives. This was not a professional organization, but an attempt to focus on providing better maternity care for women and babies.

However, the lack of a true professional organization for the nurse-midwives was soon felt. Unable to find a good niche for themselves in other health-care professional organizations, nurse midwives in 1955 formed the American College of Nurse Midwives (ACNM), still extant today. Their initial goals were to develop educational standards, sponsor research and participate in the International Confederation of Midwives. The formative purpose of the ACNM was to promote and protect the profession of nurse-midwifery, and in doing so it was an enormous step forward for midwifery.

At the same time, the baby boom was occurring, and city hospitals were overwhelmed with the sheer number of birthing mothers. To reduce costs and meet staffing needs, hospitals began to hire large numbers of nurse-midwives, and thus the transition of nurse-midwifery into a hospital-based instition began - and has really never reversed. Nurse-midwives now overwhelmingly work in hospitals and attend hospital births.

There were several positives to this shift into hospital-based work. Nurse-midwives were now able to serve more women, able to increase their knowledge-base by serving cases with complications (which in homebirths would have been risked out to hospital care, as they are today), able to better serve the needs of the poor, and also able to more firmly establish themselves in the maternity system. Because of the shift into hospital-based work, more nurse-midwifery schools opened and there was steady employment for larger numbers of nurse-midwives.

However, there was also a negative side to the shift into hospitals. Primarily this was seen in nurse-midwives' loss of autonomy and increasing subordination to doctors. Rather than always being independent practitioners in charge of women's health-care, nurse-midwives were now subordinate to the doctor in charge, and in many cases became nothing more than glorified obstetrical nurses (something that holds true today).

In-hospital conflicts for nurse-midwives have never disappeared. Although nurse-midwives are still entrenched in the hospital system, they are still often treated as nurses and are under the authority of physicians. Additionally, because of intervention-heavy hospital protocols, they are often forced to practice against the midwifery model of care, resulting in births that are midwife-atended but still heavy on unnecessary and dehumanizing interventions. Also, the training and hospital work of nurse-midwives can unfortunately produce midwives who are more obstetrically-minded than midwifery minded (called "med-wives") who are no longer practicing according to midwifery standards but have conformed in both thought and behavior to the model of mainstream birth as a medical event. Thus, although nurse-midwives are able to provide hospital midwifery birth services to women who want hospital births (which is the majority of modern American women), their practice and sometimes their beliefs can be negatively altered by their chosen place of practice.

For nurse midwives, the shift to hospital-based work was so complete that in 1973 the ACNM published a statement against homebirth, saying that the hospital was:

"the preferred site for childbirth because of the distinct advantageto the physical wefare of mother and infant" (ACNM 1973, quoted in Rooks 1997:67, quoted in Davis-Floyd 2006:36)

(This statement was retracted in 1980.)

During the 1960's and 1970's the profession of nurse-midwifery made great strides. Although in 1963 there were only forty nurse-midwives practicing in the United States, the ACNM was making great strides in terms of developing the profession of nurse-midwifery. In 1965 the ACNM developed their accreditation process, and by 1970 it was administering national certification and accreditation for all nurse-midwifery programs. In 1978 the ACNM defined the core competencies for nurse midwifery (core competencies are "the fundamental knowledge, skills, and behaviors that are the expected outcomes of..... education", p. 38) and by 1980 there were nineteen nurse-midwifery education programs, with nurse-midwifery legal and protected in 41 states. Nurse-midwives attended approximately 1% of all American births.

***

And now we examine the other side of the coin: We will examine the story of the lay midwife, also called the direct-entry midwife (DEM) who is not a trained nurse and who often learned her trade by apprenticeship.

In the 1960's and 1970's there was a reactionist movement (mixed together with the countercultural and feminist movements) against the extreme medicalization and often brutalization of birth in American hospitals. At the time women were isolated from family during birth, physically restrained, and forcibly anaesthetized during the birth process. Both mothers and babies suffered from the drugs used on them, breastfeeding was discouraged, and babies were isolated in newborn nurseries.

"From the 1930's to the 1970's scopolamine was heavily employed. A psychedelic amnesiac that was supposed to take away memory, this drug often did not render women unconscious during birth, but rather made them wild. They were strapped down with lamb's wool bands (which did not leave marks on thier arms) and often left alone to scream until the baby finally came; many women were subsequently haunted by spotty nightmarish memories. Technological interventions such as forceps and episiotomies became increasingly common as humanistic care for birthing women became increasingly rare." (p. 38)

Some mothers, helped by certified nurse-midwives, tried to change and improve hospital birth for the better. Benefits gained during this time included getting fathers into the delivery room, permitting mothers to labor without being restrained and the promotion of conscious birth and breastfeeding. However, change was limited and slow.

Frustrated with slow change, women within this movement began to give birth at home. Since there were oftentimes no midwives to attend them, these women became each other's midwives - attending births of friends and families and slowly building their knowledge-base by experience and self-teaching. They became the first generation of the resurgence of the lay midwife. As time went by lay midwifery grew in numbers and knowledge, formed relationships and began producing literature, such as Ina May Gaskin's "Spiritual Midwifery."

Lay midwifery was not well-received by nurse-midwifery. To put it succinctly, "They're destroying everything we've worked for!" Nurse midwives stood for credibility, professionalism, standards of care, medical orientation, protocols, etc. Lay midwifery stood for women's rights and natural birth and was often hippie-ish and spiritual in nature (especially in the early days), making nurse-midwives fear for the credibility of midwifery professionalism. Thus began a conflict between schools of thought in American midwifery which has never been completely healed, and which has often caused deep and bitter resentment and divide between the two camps. (In fact, the divide and the conflict has often been so deep and problematic that American midwifery has been used by other nations, Canada in particular, as a model of how not to do midwifery.)

In 1981, Sister Angela Murdaugh, then-president of the ACNM, met with a group of lay midwives and, in a controversial move, urged them to organize and create principles of practice by which lay midwifery could be organized and made more professionals. Sister Angela received a great deal of opposition from within her own ranks in the ACNM - many nurse-midwives felt that lay midwives should either be discouraged from practicing altogether or encouraged to become nurse-midwives and join the ACNM. However, Sister Angela's courageous move gave impetus to the lay midwifery movement and started wheels turning for the organization of lay midwifery. However, the two professions remained separate and did not in any way unite. Although the ACNM had in 1980 made a counter-statement now supporting homebirth, the ACNM did not open to lay midwifery until 1994 - by which time lay midwifery was already well organized on its own and did not need the ACNM's help.

And so the stage was set for one of the biggest accomplishments for lay midwifery in America - the formation of the Midwives Alliance of North America (MANA), a coalition formed by lay midwives and some sympathetic nurse-midwives. There was no nursing requirement for membership, as nursing was seen by nurse-midwives to be detrimental to the practice of true midwifery, the two having completely different philosophies and knowledge-bases.

"As these original lay midwives became more sophisticated in their understanding of the details of medical training an dpractice, they saw quite clearly that what they were seeing at homebirths often did not reflect what they were reading about and seeing in hospital birth. Understanding that they were developing a different knowledge system, over time they sought to develop educational methods and programs that would perpetuate that systyem, and to avoid incorporation into the more medicalized nurse-midwifery approach." (Anne Fry, quoted on p. 43)

MANA and lay midwifery thrived despite ill-wishes of the medical and nurse-midwifery community and despite active persecution law enforcement. Occasionally supportive CNM's joined MANA as well (MANA valued inclusivity and welcomed nurse-midwives).

However, MANA was not then an official professional organization because, at the time, it had no ability to enforce its core competencies as educational requirements, and thus was open to the accusation of illegitimacy as an professional organization.

In the late eighties and early nineties, meetings called the Carnegie Meetings were held between MANA and the ACNM to try to create much-needed unity. While each deemed that their core competencies were equivalent, the philosophical divide between the two was too great to achieve unity.

One of the most deeply divisive issues at hand was that of apprenticeship. ACNM holds that apprenticeship is an invalid and incomplete method of training, and that only a university degree can validly qualify a midwife. MANA holds that apprenticeship is a valid route to midwifery training, and furthermore, that it is an essential method that preserves the midwifery model of care, and additionally, that university training in a traditional setting can be destructive to the formation of holistically-minded midwives.

(Speaking as a woman who was cared for by apprenticeship-trained midwives, I wholeheartedly agree with MANA's position and view apprenticeship as vital and essential to midwifery education. I now would not want to be under the care of a midwife trained any other way. - Author)

In 1991 MANA created the Midwifery Education Accreditation Counsel (MEAC) which was recognized by the US Department of Education in 2001, comparable to the ACNM's Department of Accreditation (DOA) which was recognized by the Department of Education in 1982. Thus MANA was well on its way to becoming more "professional." MANA recognized the need for a mechanism to prove the competency of its midwives. Most lay midwives had already dropped the term "lay midwife" for the term "direct-entry midwife" (DEM), by which they meant apprenticeship-trained or non-university-trained midwives. Thus, by 1994, MANA's daughter organization the North American Registry of Midwives (NARM) had developed into a testing and certifying agency and had developed the Certified Professional Midwife (CPM) credential, a credential that recognized formal training, self-training, apprenticeship training and portfolio work for credentialing as well as designing the NARM written and practical exam for licensing.

"CPM certification is competency based; where a midwife gains her knowledge, skills, and experience is not th eissue - the fact that she has them is what counts." (p. 53)

At the same time, certified nurse-midwives were reexamining their self-identity. Many wished to break with nursing, for some of the following reasons: (1) they were tired of being treated as glorified nurses, (2) they desired autonomy from doctors and state nursing boards, (3) Physicians Assistants had started attending births, and (4) the realization that only some nursing knowledge is needed for midwifery. Nurse-midwives thus created the Certified Midwife (CM) credential, a certification that maintains the tradition and philosophy of nurse-midwifery without the nursing requirement. Nurse-midwives refer to the CM as their direct-entry midwife, creating some confusion as to what a DEM really is.

In summary, America has two basic types of midwives:

Type #1: Nurse Midwife
Includes: Certified Nurse-Midwife, Certified Midwife
Professional Organization: ACNM (American College of Nurse Midwives)
Accreditation Organization: DOA (Department of Accreditation)
Location of Practice: Mostly hospital, occasionally birth centers and home

Type #2: Lay or Direct-Entry Midwife (DEM)
Includes: Lay Midwife, Licensed/Unlicensed Midwife, Certified Professional Midwife
Professional Organization: MANA (Midwives Alliance of North America)
Accreditation Organization: MEAC (Midwifery Education Accreditation Counsel)
Location of Practice: Home (may not practice in-hospital in America)

A few other notes:

The legality of homebirth DEM's differs greatly from state to state. In about ten states (poor pitiable places) lay midwives' work is 100% illegal, and midwives must work underground. In other states it is "a-legal" - neither legal nor illegal, but midwives maintain a tenuous position of being open to prosecution in cases of poor neonatal or maternal outcomes. In other states (such as Arizona, hurray!) midwives are legal and may practice openly, though they still deal with backward attitudes in hospitals and from doctors.

Midwives' legal scope of practice varies widely by state as well. For example, homebirth midwives may deliver twins in California, but not in Arizona; they may deliver VBAC babies in Utah, but not in Arizona.

Additionally, some states allow midwives to practice while unlicensed, such as Utah and Oregon (Arizona doesn't).

I'd like to look at a few other terms:

"granny midwife" - a term for an elderly female midwife, usually black, who served her ethnic community, generally in the deep south. These women were effectively put out of business by the health departments.

"plain midwife" - a midwife, usually unlicensed and unregistered, who works (often unpaid) among her religious or ethnic community. Examples are Amish & Mennonite midwives, and midwives who serve Mormon communities and Christian Scientist communities

"renegade midwife" - there are a couple of different types here:

(!) a midwife who practices without sufficient training and is dangerous to the community - few and far between, but it does happen. These are not licensed midwives, but unlicensed lay midwives who branch out on their own when they should still be studying or learning under apprenticeship

(2) a midwife who practices outside the legal scope of practice for her region but is generally considered responsible by the midwifery community. For example, a midwife might attend VBAC homebirths, which are considered safe by midwives (VBAC's are generally only risky when labor-augmenting drugs are used) but are often illegal by state licensure laws

(3) a midwife who attends women at home in risky situations, such as triplets, etc. These women can be risk-takers but are often valued by the community as midwives who keep options open for birthing women. (I, for example, support a woman's right to birth how she wishes, even if a hospital birth is medically indicated. But midwives who don't want to endanger their licensing or ability to practice are often reluctant to take on such mothers, even though they support mothers' rights. This type of renegade midwife ensures that mothers retain their rights even when other homebirth midwives have to turn them away. - Author) However, they can give the midwifery community a bad name.

Midwifery in America is a constantly growing, changing, evolving profession, and one which I am glad that I now know of! I love midwives and am so happy to have several among my close acquaintance.

***

That's about it! If you see any omissions or errors, please contact me, as I want the above to be as accurate as possible.

***

Postscript on January 5th, 2009:

The Mommy Blawger sent in the following comments, which I wanted to add below, as they're both very pertinent points which I should have included in the article:

"I will make just one or two additions. First, since the rise of the CPM credential, the term "lay midwife" has taken on an almost pejorative meaning, and is almost exclusively used (at least by midwives) to refer to women without any formal midwifery training or credential.

"Second, many (including myself) believe that there is no such thing as an "alegal" state. Either a state recognizes/permits/regulates direct-entry midwifery, or it doesn't. In a state where midwifery is not "authorized", even if there is no statute specifically prohibiting DEMs, a midwife runs the risk of being charged with practicing medicine or nurse-midwifery without a license, or a number of related offenses. You can see that in states such as Pennsylvania, which was formerly described as "alegal", it took only one bad outcome for the powers-that-be to start actively prosecuting midwives.

"Your readers may be interested in this resource for more on the legal status of midwifery:
http://fromcallingtocourtroom.net/


8 comments:

  1. Diana, do you have a good recommendation for a book that has no agenda, but that promotes both sides (hospital birth and home birth) equally and fairly, examining the pros and cons of both. Everyone I know who has an opinion on the matter has a really *strong* opinion and that's not very helpful for me at this stage because it's hard for me to sort through the bias (I don't mean that offensively at all!). I am starting to get a *little* more interested in the idea of a midwife and/or homebirth (many thanks to you!!) and I'd really like to read more, but preferably from both sides of the aisle because I still have a lot of fear about a homebirth, and I don't know that a book strictly advocating that will assuage those fears. Maybe there are even resources/writings from women who have done both?

    ReplyDelete
  2. Jen, Dr. William Sears has a book you may be interested in, called "The Birth Book." He is certainly not anti-hospital, nor anti-home-birth. It's been a while since I read the book, but I'm pretty sure he gives the information and lets you draw your own conclusions.

    You should also read Henci Goer's "The Thinking Woman's Guide to a Better Birth." It is full of information you can use. While she is definitely pro-natural-birth, she gives you information on all choices, and at least is honest about her biases (unlike so many others who are not up-front about the fact that they are anti-home-birth). It is the book I would recommend that everyone take into the hospital with them, if they plan a hospital birth, so that they can use it as a reference in labor if need be. She is a very thorough researcher, and doesn't just tell you her conclusions, but shows you her sources so you can do the research yourself.

    I think both of these books are written with the assumption that most of the readers will be planning a hospital birth and will probably give birth in the hospital, since only about 1% of births take place outside a hospital.

    -Kathy

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  3. Thanks Kathy and Diana.

    I guess I just come at it differently. For me, this isn't a moral or ethical decision. I want to do what's best for me and the baby (babies?) but I'm not convinced that that answer is always the same for every family, or even every pregnancy within one family. I want to know what all my options are, but I want to examine them neutrally or as neutrally as possible. I don't want to choose out of fear or pressure--I just want to be able to compare everything side by side and go with the one that we think best fits our needs.

    Random question-I was immediately drawn to the idea of a birthing center, but the only one I can find in Arizona is in Tucson-is that correct?

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  4. I'll have to leave the specific question about the birth center to Diana, but must say I agree 100% with you about birth not being "one size fits all"! There are so many factors that go into the decision of where to give birth -- or at least, that *ought* to go into that decision! -- that one can't just say, "home = good; hospital = bad."

    Some women just don't want to give birth at home (for whatever reasons -- fear, wanting an epidural, wanting to be in the hospital "just in case" or whatever); others may have too much mental baggage to do it -- my sister was that way -- she spent most of her stalled labor thinking about the mess in the closet and the dirty carpet they hadn't been able to replace prior to the baby's birth. I think she was literally too hung up to give birth at home because of that -- she quickly and easily dilated the remainder of the way soon after they transferred to the hospital (after being stuck at 6 cm for 9 hours).

    I think that the important thing for any woman to do who is considering where to give birth is to ask what herself what her priorities are, and which birth scene is most likely to fit those priorities.

    Here is a great essay by a fellow childbirth educator that sums up this thinking process quite well, I think: (http://www.birthnaturally.org/BurgerKingBirth.pdf). And the book by Henci Goer I mentioned previously does look at many of the questions concerning and differences between hospital and home birth (you can check it out from the library, probably getting it through interlibrary loan, if necessary).

    One difficulty in trying to find "unbiased" sources is that most of the time people who are not anti-home-birth are strongly pro-home-birth... for a reason. :-) Most of the home-birth people I know have had at least one hospital birth and decided there must be something better. While they would support a woman's informed decision to give birth wherever she chose, they are so strongly pro-home-birth that they could not be unbiased. But we can still be fair. :-)

    -Kathy

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  5. Great job! Thanks for this great article. I will make just one or two additions. First, since the rise of the CPM credential, the term "lay midwife" has taken on an almost pejorative meaning, and is almost exclusively used (at least by midwives) to refer to women without any formal midwifery training or credential.

    Second, many (including myself) believe that there is no such thing as an "alegal" state. Either a state recognizes/permits/regulates direct-entry midwifery, or it doesn't. In a state where midwifery is not "authorized", even if there is no statute specifically prohibiting DEMs, a midwife runs the risk of being charged with practicing medicine or nurse-midwifery without a license, or a number of related offenses. You can see that in states such as Pennsylvania, which was formerly described as "alegal", it took only one bad outcome for the powers-that-be to start actively prosecuting midwives.

    Your readers may be interested in this resource for more on the legal status of midwifery:
    http://fromcallingtocourtroom.net/

    ReplyDelete
  6. I am wondering...is there such a thing as a "lay midwife" (no formal training) in the state of Arizona? If so, is it legal for her to do some prenatal care? (mostly making sure head is down and checking heart rate) I will be having the baby in Indiana with a midwife there.

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  7. While it's possible that there might be lay midwives in Arizona, I rather doubt that there are many, since Arizona licenses direct-entry midwives. That being the case, anyone practicing midwifery who is not either a LM, a CNM, or a doctor could be charged with practicing medicine or midwifery without a license.

    For more information about Midwife licensing in Arizona and to locate a midwife, check out:
    http://www.azdhs.gov/als/midwife/

    ReplyDelete

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