The history of midwifery looks different around the world. Its path in the United States has followed many twists and turns. In the early parts of the 19th century, midwifery was the most customary practice for pregnancy care and childbirth. By 1980, midwives attended only 1.1% of births. In contrast, midwives attended almost 12% of United States births in 2020. Why have these numbers fluctuated over time? 

In honor of National Midwifery Week, we spoke with Venay Uecke, C.N.M., OHSU Midwifery clinical instructor and practice manager of the Hillsboro Medical Center Midwife Faculty Practice, to learn more about the American history of midwifery.

“We don’t have the complete history, because a lot of it has been erased through the powers and forces reflective of racial, political, gender, and socioeconomic oppression,” says Uecke. “But midwifery is one of the oldest professions, not only in America, but worldwide.”  

Midwifery in the Colonial Era

Women-centered childbirth, practiced by apprentice midwives, played a pivotal role throughout Europe, Asia, and Africa. The same was true on American soil until the 20th century. In colonial times, midwifery reflected women from all backgrounds, including enslaved Black women, who worked as enslaved midwives in the antebellum South.  

In this tradition, midwives learned through apprenticeship from experienced, older midwives. They traveled to homes to care for mothers and their babies. Midwives were critical to their communities and often the only primary care providers. They put forth all of their skills to care for women in the traditional sense, which included wellbeing manifested through physical, emotional, mental and spiritual aspects.  

The rise of obstetric medicine

A stark divide began to take root in the 1800s, when white male physicians began to explore childbirth with greater interest. Their approach was based on a colonialization framework, which devalued birth as ceremony and focused instead on the physical aspect of wellbeing.  

Many doctors opposed midwife-assisted births. They launched campaigns against the profession, promoting Western science and the pain relief that hospitals could offer. By the turn of the century, they attended approximately half of births, despite having little training in obstetrics.  

In rural America, however, midwives continued to attend births. In the Southern states, Black midwives, sometimes called “granny” midwives, attended up to 75% of births until the 1940s. A combination of laws, educational restrictions, and campaigns against the profession led to the dismantling of their practice. 

Midwifery in the 1910s-1920s

Several important milestones happened in the early part of the 1900s that had a profound impact on midwifery: 

• The 1910 Flexner Report recommended hospital deliveries and the abolition of midwifery. The study has since been recognized for its racist, sexist, and classist approach to medical education. 

• “Twilight sleep” was introduced in 1914, an amnesiac given to women preventing any memories of giving birth. 

• In 1915, Dr. Joseph DeLee – a prominent obstetrician – called pregnancy and childbirth “dangerous” and “evil.” Dr. DeLee promoted the use of forceps, sedatives, ether, and other interventions that needed hospital-level care. He argued that midwives were incompetent. 

• The Department of Indian Affairs passed legislation that moved births from the home to the hospital. 

• The Shepphard-Tower Infancy and Protection Act became a federal law in 1921. It encouraged states to develop their own maternal and child health legislation. Before these changes, lay midwives practiced mostly without restrictions. The new laws severely reduced their practice in many states. For example, Alabama began requiring all midwives to obtain a license, then later required nurse-midwives to practice only in hospitals. These changes prevented 150 “granny midwives” from practicing across the state practically overnight. 

The beginnings of nurse-midwifery

The more formalized field of nurse-midwifery also developed at this time. Public health nurse Mary Breckenridge founded Frontier Nursing Service (FNS) in rural Kentucky in 1925. Praised by some for creating a pathway for midwifery education and certification, Breckenridge’s racist and xenophobic past is controversial. Her stance impacted midwives of color for years to come. 

“Mary Breckenridge’s beliefs reflected racist values and did not allow African American women to be educated as midwives,” says Uecke. The formalization of education and certification ultimately delegitimized apprentice-trained midwives in every community.  

Denying education to midwives of color has had a lasting effect on communities that relied on them for care. Today, less than 5% of midwives in the United States are people of color. Disparities in maternal morbidity and mortality rates are striking; Black mothers are 2-3 times more likely to die in childbirth than white mothers. This impact is a reflection of the powers and forces that disconnected midwives from their communities. 

“Midwives care for families and help them to thrive,” says Uecke. “When you devalue midwives, you devalue the community. Current policies prioritize separating women from their support networks. Sometimes, being alone and unsupported creates unnecessary stress and negative health consequences. We are in a crisis here in America, and midwifery is part of the solution.” 

“Collaboratively, healthcare providers and systems need to promote inclusion,” adds Uecke, “Our mothers are dying, and the system should change to enhance outcomes. We need a collective response to work towards a common goal of creating safe spaces for giving birth.” 

The return of midwifery begins

The decline in midwifery-attended births in the 20th century began to reverse course in the 1960s and 1970s. The Women’s Movement fueled efforts for women to reclaim their own bodies. Midwife Ina May Gaskin became an active voice in promoting family involvement in birth and reducing interventions. Birth centers and midwifery programs began to form. 

“The midwifery plan of care promotes a power-with relationship based on informed choice and recognizing women have control over others ways of knowing. It incorporates their own knowledge of their bodies, feelings, and past experiences, as well as their lifestyle and personal philosophy,” says Uecke. “That’s where midwifery shines.” 

Today, more than 98% of births in the United States take place in hospitals. In some industrialized countries, such as Sweden, France or Japan, midwives attend close to 75% of births, in hospitals, birth centers, and homes. While the profession has much to contend with in its history, American midwifery today is on the rise.