From my drafts folder -- Midwifery in the 20th Century

In preparing the book proposal I sent to the American Association for State and Local History Press for my work in progress, Exploring American Healthcare through 50 Historic Treasures, I wrote expanded versions of two of the chapters that will appear in the book. The following is an excerpt from one of these expanded chapters. The chapter as it will appear in the book is centered around the midwife kit that belonged to Rosa Bonfante, who practiced in the early 1900s, and the debates about midwifery in the early 20th century. This version summarizes what happened in the following decades. 

If Bonfante was young when she immigrated to the United States, she might have worked as a midwife long enough to see quite a few changes in the culture of childbirth. With the advent of sulfa drugs (sulfonamides) in the 1930s and penicillin in the 1940s, puerperal fever was no longer a likely death sentence. In the mid-1930s through 1950s, maternal mortality finally decreased, after having risen in the late nineteenth century. Doctors were better trained than before. Antibiotics and safe blood banks also played a notable role in this change. In this same period, Cesarean sections replaced the use of forceps for certain types of complicated birth. Doctors’ opinions on how quickly to turn to a Cesarean section varied, much in the way nineteenth century doctors had differed on using forceps. The baby boom from the 1940s through 1960s created the conditions for more diverse practices of birth to flourish, as there were more people giving birth.

By the 1950s, American society started to question the extreme medicalization of birth. In 1957, the Ladies’ Home Journal printed a letter about cruelty in maternity wards. In response, hundreds of women wrote in to share their own dehumanizing and unsafe experiences. Some were restrained for as long as eight hours. In this era, doctors began to center the birthing mother. One leader of this change was Dr. Fernand Lamaze, a French obstetrician who advocated breathing and relaxation to help with pain, and giving women confidence in their role in the birthing process. In 1959, Marjorie Karmel popularized his work in the United States with her book Thank You, Dr. Lamaze. Also in the mid-twentieth century, an anti-anesthesia philosophy became popular -- the idea that women only feel pain during childbirth because they expect it or are afraid. Some women continue to subscribe to this belief, while others say it minimizes women's pain.

The second half of the century saw a resurgence in midwifery. Beginning in the 1960s, nurse-midwives were hired in new federally-funded programs to expand access to healthcare. In 1960, the FDA approved the first hormonal birth control pill. As discussed in the chapter “The Pill and Advances in Birth Control,” women had more ability to control their reproductive lives, and expected more choices in the birthing process. Feminism and New Age movements encouraged home births, often attended by a lay midwife. A number of hospitals created their own birthing centers starting in the 1980s. They blended medical interventions and the gentler practices of late twentieth-century home birth and natural birth. In the 1980s and '90s, the medical field began to value professions sometimes called “physician extenders,” or more recently “allied health.” This shift included an increase in trained nurse-midwives.

Despite this apparent trend towards harmony between doctors and midwives, the late twentieth and early twenty-first century have still seen tension between different approaches to birth. Midwives only attend around 10 percent of births in the United States. Still, interest in home births and midwife-attended births is alive and well. Obstetricians are recommended for high-risk pregnancies, and some caution that any pregnancy can turn high-risk. Risk is estimated using the fetus's position and the mother’s age, health, weight, and history of childbirth complications. Meanwhile, some midwives feel obstetricians are too eager for interventions. Public health groups sometimes suggest expanding midwifery to fill geographic gaps in birthing care coverage. However, as many insurance plans don’t cover births attended by midwives, they are no longer a more affordable alternative to the doctor.

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Borst, Charlotte G. Catching Babies, The Professionalization of Childbirth, 1870–1920. Reprint 2013. Berlin, Boston: Harvard University Press, 2014. doi:10.4159/harvard.9780674733480.

Ettinger, Laura. Nurse-Midwifery: The Birth of a New American Profession. Columbus, Ohio: Ohio State University Press, 2006.

Litoff, Judt Barrett. American Midwives: 1860 to the Present. Reprint edition. Westport, Conn: Praeger, 1978.

New York Times. “Opinion | Are Midwives Safer Than Doctors?” The New York Times, December 21, 2017, sec. Opinion. https://www.nytimes.com/2014/12/15/opinion/are-midwives-safer-than-doctors.html.

Wertz, Richard W., and Dorothy C. Wertz. Lying-In: A History of Childbirth in America. First Edition edition. New York: Free Pr, 1977.