Midwifery in the United States (U.S.)

Several developments were taking place in the U.S. alongside the evolution of midwifery in Britain; these would lead to a very different outcome for midwives and women. It is important to consider the developments in the U.S. as doctors there have taken the lead in childbirth over the past century across all spheres, virtually eliminating midwives and midwifery for a substantial period. This would have been one possible outcome for midwifery in this country had the Midwives’ Institute, or some similar group, not taken an active role in ensuring its preservation. Also the relative power of the U.S. as an international trendsetter means that approaches to birth there have impacted on the norms throughout the Western world.

Several factors impacted on the possibility of maintaining a distinct occupational group in the U.S. These included the economic importance of midwifery to medical men, the lack of upper class patronage of midwives, increased emphasis on science (or technology) in medicine and the lack of any organisation of midwives in a large and decentralised country (Arney 1982). Indeed the word ‘midwifery’ was largely dropped after the American Medical Association was started in 1847 as the scientific division of ‘obstetrics’ was considered preferable (Arney 1982). By the time midwifery was being enshrined in statute in Britain, there was a substantial move in the U.S. to remove midwives from the system of health care altogether.

Dr. Henry Garrigues published a book in 1902 (Oakley 1989:214) which dismissed any sound basis of midwifery practice suggesting that “midwives do harm not only through their lack of obstetric knowledge, their neglect of antiseptic precautions, and their tendency to conceal undesirable features, but most of them are inveterate quacks”. Barker (1998) points out that the publication of ‘Prenatal Care’ was a systematic attempt to introduce women to a medical interpretation of pregnancy in 1913 in the U.S. This document was distributed to well over twenty two million women by the mid-thirties and effectively led to the reconceptualising of pregnancy as medically problematic rather than as an ‘experientially and organically demanding’ social transition (Barker 1998).

This widespread dissemination of medical propaganda in the early twentieth century was an important and explicit means of leading American women to the belief that they need hospitals and technology to give birth and obstetricians to safely control that process. Davis-Floyd (1998) confirms that this belief colours women’s perceptions of their own bodies and their ability to give birth normally and remains prevalent today. Rothman (1996) supports the idea that American women have been systematically stripped of power and control through the routine management of childbirth. The campaign from the early twentieth century appears to have been very effective in redressing much of American society’s expectations of birth and in setting up obstetricians with ultimate authority in its control.

It is not surprising that midwifery was all but eradicated in the U.S. (Mander 2002) until a resurgence of interest by women in the past few decades led to the creation a relatively new practitioner, the ‘nurse-midwife’. The ‘nurse-midwife’ appears to be a being more socially acceptable to the medical community. It is likely this acceptance is based on two factors: nurses have limited autonomy or authority in practice (i.e. they provide the treatment prescribed by doctors) and their training/ education is based in the biomedical approach to health and health care and they are, therefore, likely to accept intervention as routine. These nurse-midwives practice primarily in hospitals with only a few supporting women outside of the mainstream obstetric system (Davis-Floyd & Sargent 1997).

However through the twentieth century, lay midwives did remain prevalent in the U.S. in very specific areas, those of deprivation, remote access or minority ethnic cultures (that is, those areas least likely to provide lucrative employment for obstetricians). There are some notable examples of innovative midwife led care initiatives led by organisations like the Maternity Center Association (Lubic 1979). In addition, lay midwives have continued to practice in specific areas like the commune in Tennessee, called ‘The Farm’ from which Ina May Gaskin has become very well known internationally. These examples are far from the norm, however, and are based in areas of little prestige or limited potential financial gain. There has been an increased number of midwives who have not come from a nursing background in the past twenty years (known as the MANA -Midwives of North America, an organisation created in 1982- midwives) but there is still widespread scepticism about their legitimacy. They largely practice primarily in free standing birth centres or in supporting home births.

Therefore, in the U.S., midwifery has developed in a very different direction than in Europe. The intentional devaluing of traditional midwifery, through the systematic dissemination of propaganda that claims obstetrics as the only safe option of care for childbearing women, has relegated midwives into relatively powerless pockets of practice. Despite the resurgence of some interest and support for midwifery practice, it remains marginal in a medically dominated health system. Technology is considered as an essential part of safe childbirth and that technology is largely the domain of medicine. Midwives, although growing in number as a result of interest by women, are generally still considered as fringe despite their efforts to meet the requirements for in depth knowledge of the ‘science of obstetrics’. This adversarial approach to birth, with midwifery opposed to obstetrics as the legitimate authority on childbirth, is less explicit in Britain but the developments in the twentieth century have meant that it exists nonetheless (Taylor 1999).