Someone Call the Midwife

            Second to the worlds oldest profession would be the world’s second oldest profession, midwifery. Midwifery is defined in the Encyclopædia Britannica as a health science and health profession that deals with pregnancy, childbirth and postpartum care, or newborn care.[1] Many historians have discussed the particulars of the profession. This is not the first time that midwifery has made a resurgence in recent memory, as it is a profession that waxes, and wanes based on social norms of the time, which is why it is so interesting to look at midwives through a historical lens. Several of the articles and pieces in this writing will discuss the ins and outs of the profession through the many different historical periods, starting with Victorian England, moving to the United States after the implementation of the Midwives Act across the ocean and what happened over the twentieth-century and finally moving in to the modern age and to the place that midwives hold within society today around the world as well as the gendering of women’s healthcare.

            In 1902, the Midwives Act of 1902 was passed by the British Parliament. This was one of the many jobs that were becoming more professionalized at the time including nursing jobs, as that profession was becoming more respectable at the beginning of the twentieth century. Susie Steinbach writes in her book, Understanding the Victorians: Politics, Culture and Society in Nineteenth-Century Britain, about the professionalization of midwifery and nursing. This was also an issue of status, as typically, midwives and nurses were fairly uneducated, and in 1881 the Trained Midwives Registration Society, later renamed the Midwives Institute was founded. Steinbach writes that, “…the Trained Midwives Registration Society was founded by middle-class and upper-class women who wanted professional status. But in spite of campaigns for formal training and registration, most midwives were working-class women who served their local communities. Middle-class  and upper-class women insisted on male attendants, often obstetricians rather than midwives. In 1902, formal registration was made a requirement for practice.”[2] The passage of this act was an important step in regulation of womens health, as well as a creation of formal jobs for many women. The job of midwifery had often been left to those who had experienced child birth themselves, but as Steinbach continues, “…very different types of women entering midwifery. Where before the turn of the century most midwives were older, working-class, often widowed, and usually without formal training, after the Midwives Act there was a shift to women who were younger, unmarried, from a broader socio-economic spectrum, with formal training in both nursing and midwifery.”[3] This shift to a broader spectrum of women entering the midwife profession was felt around the world, and it finally established standard for midwives around the world, not only in England.

            In an article published in The British Medical Journal in 1907, nearly five years after the passage of the Midwives Act, the board wrote about the actual implementation of the new standards. The local governments were charged with handling the trainings and certifications of these women who wanted to partake of the profession of midwifery, but they needed to have a board who had equal training and accountability, which was difficult at the time.[4] Overall, the article praised the Central Midwives Board, but many found that this was a platitude, and truly did nothing more than to endorse the passage of the law. In her article Lara Foley speaks to the marginalization of midwives across the ocean in the United States, as these women were also being watched for mistakes and shortcomings, while undergoing training. Foley writes, “In the United States, midwifery is an occupation that exists on the fringes of the mainstream medical system. Under the threat of attack by the medical profession, the media, and lawmakers, midwives often feel a need to legitimate their occupation and activities.”[5] Foley’s article examines the stories of twenty-six midwives in different areas of the United States. She asks for their opinions and stories of experiences they have had, and places them within the context of the time. She examines the force that laws exerted on these women, and how it would shape the next generation of midwives as well. Foley continues about these women and what they called different historical periods. One such period, she talks about was what these women called the “granny era.” “Scholars describe “traditional” or “granny” midwives as both black and white women who became midwives in response to the needs of their communities, especially in the southeastern United States. Typically, these women felt “called” to midwifery and learned through apprenticeship with an older midwife. Because the women they cared for often had little access to health care, these midwives attended complicated births as well as normal deliveries.”[6] Midwives around the world and across the United States played a crucial role in women’s healthcare, as many of the women who used midwives or gave birth in the home were either too poor to afford healthcare or they may not have had access to a hospital or doctor, though this would have mostly been in rural areas. These women, midwives, felt a calling to the profession, as many women did at the time. Becoming a midwife was one of the professions that was becoming more respected and less of a job that you took because you had to at the turn of the century. The professions of nursing and midwifery were becoming more highly regulated and, in many cases, required a more thorough training and certification than before. In the coming decades, there would be many questions about what changes were to come to the profession and what this would mean for the women who had already made their mark in the profession, as well as the many women and men entering this field.

            Perhaps one of the oddest things to happen to the profession was when women’s healthcare became gendered. This had many effects. One such effect was that men did not entirely feel welcome to the profession of midwifery any longer, as was the case in Australia. We still see this today, as nurses tend to be female, and a fair number of obstetricians are male. In an article written by Elizabeth Pittman and Les Fitzgerald, they discuss this change. They collected stores of forty men who entered the nursing profession between 1950 and 2000, as well as twenty additional men who entered the profession of midwifery between 1970 and 2000. They write about the changes to the midwife and nursing profession in the 1950s, “…the Nurses’ Registration Act in the states of Victoria (1958) and Tasmania (1952) that barred men from midwifery practice. Using historical documents and oral testimony, this paper outlines how John Chapman was instrumental in changing the Nurses’ Registration Act (1952) and was the first man to become a midwife in the state of Tasmania, and Christopher James and Alan Gibbons’ separate campaigns to change the Nurses’ Registration Act (1958) in Victoria.”[7] The 1950s seems to begin where the gender divide really picked up. Their article provides evidence for these men and show a struggle beyond the women working in the profession, as had been the standard for many years.

            Monica Green writes even further on this topic in her article, Gendering of Women’s Healthcare. Green is concerned with how history has shaped the view of healthcare, and midwives. She examines many aspects, but her purpose is to look at the history of women’s healthcare through a gendered lens, because it is entirely possible that such a lens is needed for people and fellow historians, to understand the full context of the changes to healthcare over time. She states, “I propose that it might be worth exploring a gendered history of women’s healthcare and fertility control, one based on the premise that knowledge about anatomy, physiology or therapeutics does not arise fundamentally out of one’s biological nature but from the experience of living in a social world where all forms of knowledge are gendered, both in their genesis and in their dissemination. As such, medical knowledge, and the practices that arise out of it, proves to be very much a part of history, continually in flux and contested. I focus on two topics that have been central to feminist studies of medical”[8] Green discusses how sexual matters and birth had been the woman’s domain, and the private sphere up until the 1800s, when men were finally allowed in the birthing room for more than just emergencies. She continues throughout her article to talk about experience, and how it is possible that a woman dominated profession of midwifery may have prevented potential advancements for many years. She continues on with a request to consider the following claim, “Childbirth was the undisputed domain of midwives for well over a thousand years. The midwives of [pre-modern] times were probably folk healers who not only attended births but generally ministered to the health needs of the common people . . . Birth was then clearly considered women’s business, a definition of the event that was shared, apparently, by all members of society.”[9] The change of domains that began to take place in the profession of midwifery is an interesting one and it brings us in to the modern age, where many men are part of the profession that had largely been considered the job of a woman.              

            Modern midwives are less common, though many women are returning to the use of midwives and doulas in place of obstetricians. In a 2005 article written by Betty-Anne Daviss and Kenneth C. Johnson discusses a prospective study and outcomes of planned home births. The study followed five-thousand and fourteen women who planned to give birth at home in the year 2000. The conclusion of the study was that, “planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”[10] In a modern age of hospitals, the certified professional midwife still plays an important role to many. In 1999, one of the requirements for recertification as a midwife was to agree to be involved in the study if asked. This lent valuable information to many and showed that the profession is still important. Perhaps it is history repeating itself, as we move back to historical methods of healthcare for women. In this case it is in the form of midwives. In many ways seems to be based on trust of the medical professional. In many cases it can be hard to form a meaningful relationship with a medical professional or doctor that you only see a few times before giving birth, where a midwife may be able to provide that companionship and a foundation of trust for their patients.

In 2017 the infant mortality around the world had a major gap ranging from 110.6 infant deaths per 1000 live births in Afghanistan to 1.8 infant deaths per 1000 live births in Monaco. Out of the two-hundred and twenty-five countries, city states and principalities the data was collected from, the United States ranked in at 170 on the list with 5.8 infant deaths per 1000 live births.[11] The Centers for Disease Control and Prevention are also interested in these vital statistics, they track the death rates, mostly in the United States, and determine the leading cause of infant mortality and maternal mortality rates during child birth. In a first world industrialized country, one would think that the infant mortality rate would be much lower than it is, however there were 23,161 infant deaths in the United States in 2016. The leading causes of the high infant mortality rate: congenital malformations, deformations and chromosomal abnormalities, disorders related to short gestation and low birthweight: not elsewhere classified and surprisingly, sudden infant death syndrome or SIDS.[12] Perhaps another study can be conducted now, such as the study conducted in 2000, where they collect data to see if the midwives are still on par with the nations hospitals as far as birth risks at home, or in the hospitals. Though the case could be made that with such a high infant mortality rate, anything would be an improvement, and perhaps the trust young mothers had, and the relationships formed between the midwives and the patients, as discussed in the North American study, would lend itself to a lower infant mortality rate in the future.

There also is a strong tie in infant mortality rates and what is perceived as socioeconomic growth. In 2009 Hulya and Murat Arik wrote an article in The Journal of Developing Areas. In their article they discuss that infant mortality is one of the more important determining factors when considering the socioeconomic development of a country. Birth rates are directly tied to whether or not the country is developed or is a developing nation.[13] In these cases, many of the developing nations still use midwives, as the people do not have access to physicians, unless they are very wealthy, which is a limited number of people. Their article discusses developing nations and the historical context of midwives within developing nations. One must wonder if the reason that some of these developing and industrializing nations have lower infant mortality rates than others, is because of the midwives in society who help the women give birth in the best way they know how.

            Midwifery is an age-old profession that is still evolving in the modern age. The preconceived notions that a midwife has to be a woman are being challenged, as are the standard for nurses and midwives worldwide. Men are entering the profession, as are more women, and recently there has been a small shift back toward home births in the United States. The majority of these go without complication and are done with little to no risk to the mother or infant despite high infant mortality rates in the United States. This profession has made a monumental impact on history, in terms of birth rates as well as the politics of laws surrounding birth, the woman’s role in and out of the home and health standards for child birth. There has been a distinct gendering of women’s healthcare over the last four-hundred years. I expect that will continue to change. Perhaps the midwife profession will continue to evolve as well as new and innovative technology yields further answers and solutions, though I expect, based on historical framework, that the profession of midwifery will be around until the end of time.

            In conclusion the historical context of different aspects of midwifery are presented in different ways. Historians studying individual decades and the evolving of women’s healthcare and the professional midwife, rather than midwifery as a whole, will have varying opinions, as noted above. Historians like Green see the gendering of women’s healthcare, and in many ways attribute this to the age-old idea that midwives needed to be women. Other historians, such as Pittman and Fitzgerald focused more on the modern changes being made to the profession, such as men taking jobs as nurses and midwives and challenging a long-held stereotype, despite this change taking place in the last century. When examining the historiography of midwifery, it is extremely important to remember that historical context is everything when it comes to the how, the who and the why. Methods of birthing have changed over time, as well as long held beliefs about home birth versus hospital birth. It can be surprising to some that there are still so many infant and maternal deaths during the birthing process, even in 2018, but the fact is, we have to use the information that has been handed down from past generations, if we want further progress. Studies such as the 2000 study of midwives show that home birth, even in the modern age, is still on par with hospitals and is still relatively minimal risk. It begs the question, why the change at all, if midwives have always played such a significant role. Perhaps we should stop trying to make the women’s healthcare field and the birthing process so exclusive. We may be neglecting insight that could be very important to the continuation of women’s healthcare around the world.

Bibliography

Arik, Hulya Arik and Murat. "Is It Economic Growth or Socioeconomic Development? A Crosssectional Analysis of the Determinants of Infant Mortality." The Journal of Developing Areas, 2009: 31-55.

Centers for Disease Control and Prevention. National Center for Health Statistics: Infant Health. 2016. https://www.cdc.gov/nchs/fastats/infant-health.htm (accessed December 14, 2018).

Central Intelligence Agency. The World Factbook. 2017. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html (accessed December 14, 2018).

Connerton, Winifred C. "Midwifery." Encyclopædia Britannica. May 25, 2012. https://www.britannica.com/science/midwifery (accessed December 10, 2018).

Daviss, Kenneth C. Johnson and Betty-Anne. "Outcomes Of Planned Home Births With Certified Professional Midwives: Large Prospective Study In North America." BMJ: British Medical Journal, 2005: 1416-1419.

Fitzgerald, Elizabeth Pittman and Les. "The Campaigns for Men to Become Midwives in the 1970s." Health and History, 2011: 158-171.

Foley, Lara. "Midwives, Marginality, and Public Identity Work." Symbolic Interaction, 2005: 183-203.

Green, Monica H. "Gendering the History of Women's Healthcare." Gender & History, 2008: 487-518.

Steinbach, Susie L. Understanding the Victorians: Politics, Culture and Society in Nineteenth-Century Britain. New York: Routledge, 2017.

The British Medical Journal. "The Administration Of The Midwives Act. The Training Of Midwives By The Local Government Board." The British Medical Journal, March 30, 1907: 758.

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[1] Connerton, Winifred C. "Midwifery." Encyclopædia Britannica. May 25, 2012. https://www.britannica.com/science/midwifery (accessed December 10, 2018).

[2] Steinbach, Susie L. Understanding the Victorians: Politics, Culture and Society in Nineteenth-Century Britain. New York: Routledge, 2017. 300.

[3] Steinbach, 301.

[4] The British Medical Journal. "The Administration Of The Midwives Act. The Training Of Midwives By The Local Government Board." The British Medical Journal, March 30, 1907: 758.

[5] Foley, Lara. "Midwives, Marginality, and Public Identity Work." Symbolic Interaction, 2005: 183.

[6] Foley, 190.

[7] Fitzgerald, Elizabeth Pittman and Les. "The Campaigns for Men to Become Midwives in the 1970s." Health and History, 2011: 159.

[8] Green, Monica H. "Gendering the History of Women's Healthcare." Gender & History, 2008: 488.

[9] Green, 490.

[10] Daviss, Kenneth C. Johnson and Betty-Anne. "Outcomes Of Planned Home Births With Certified Professional Midwives: Large Prospective Study In North America." BMJ: British Medical Journal, 2005: 1416-1419.

[11] Central Intelligence Agency. The World Factbook. 2017. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html (accessed December 14, 2018).

[12] Centers for Disease Control and Prevention. National Center for Health Statistics: Infant Health. 2016. https://www.cdc.gov/nchs/fastats/infant-health.htm (accessed December 14, 2018).

[13] Arik, Hulya Arik and Murat. "Is It Economic Growth or Socioeconomic Development? A Crosssectional Analysis of the Determinants of Infant Mortality." The Journal of Developing Areas, 2009: 31-55.