The History of Midwifery and Childbirth in America: A Time Line
Prepared by Adrian E. Feldhusen, Traditional Midwife
© 2000 Midwifery Today, Inc. All rights reserved.
Midwives and Social Childbirth in Colonial America
- In Colonial America, women attended women.
- More food and better conditions enabled better outcomes in America
than in England.
- Social childbirth—female rites performed during childbirth.
The Age of the Midwife: Before 1750
1660-1774: Parliament regulated Colonial imports and exports for
more than a century before the American Revolution. During much of that
time, the 13 Colonies prospered, as their trade was valuable to Britain.
But after 1763, restrictions upon America became increasingly onerous.
Even more serious in creating American discontent were efforts on the
part of Britain to tax the Colonies for revenue to support the British
army and officials in North America.
17l6: New York City required licensing of midwives. Such licenses
placed the midwife in the role of servant of the state, a keeper of social
and civil order.
Death during childbearing not accurately reported, but one historian estimated
that birth was still successful 95 percent of the time.
Men did not attend births during Colonial times, as it was considered
indecent. Also, there were few doctors around.
Women faced birth not with joy and ecstasy, but with fear of death and
One major reason that doctors were becoming more involved in birth was
the decline of witchcraft. Doctors did not feel comfortable around witchcraft,
and in the new colony, less was practiced.
Women began to view problems in birth as a part of nature, where doctor
ruled. They gave over medical control but not the spiritual aspect.
Medicine in a Democratic Culture: 1760-1850
Doctors were usually not educated. Books that were popular at the time
were on self-help measures, common-sense medicine.
The development of religious thought—not medical progress—first
brought about the decline of magic in healing and other spheres of life.
The Movement toward Professionalism in Medicine
1751-1850: Phase I of hospitals. Formation of two kinds of hospitals:
1) voluntary hospitals, operated by charitable lay boards, nondenominational
but in fact Protestant, and 2) public hospitals, descended from almshouses
and operated by municipalities, counties and the federal government.
1752: The Pennsylvania Hospital in Philadelphia became the first
permanent general hospital in America built specifically to care for the
1760: First licensure law calling for prospective examination of
doctors was passed in New York City.
1765: First medical school in Philadelphia was chartered.
1765: Dr. William Shippen opened the first formal training for midwives. Midwives'
beliefs that childbirth is normal and inherently within the domain of
female competence may have prevented women from seeking formal training,
especially from men. Few women were literate, many could not afford schools,
and the Puritan philosophy did not encourage education for women.
1766: First provincial medical society was organized in New Jersey.
1763: The Boston Tea Party, an act of rebellion against British
Parliament, took place in December.
1776: Declaration of Independence was signed July 4.
1787: The Constitution was signed September 17.
1796: Popular medicine included bloodletting, powerful emetics
At the end of the 18th century, most people assumed that midwives had
no formal training, even though some did, and common existing beliefs
held that women were emotionally and intellectually incapable of learning
and applying the new obstetric methods. Well-to-do families soon came
to believe that physicians could provide better care than female midwives
could and thus offered the best hope for a successful birth.
The New Midwifery
1799: A short course for midwives began in New York City, led
by Dr. Valentine Seaman. Dr. William Shippen began a course in anatomy
and midwifery in Philadelphia. Few women came as students, but men came.
1812: The War of 1812 was thought of by Americans as a "second
war of independence."
In Colonial America, women in the home routinely provided most medical
care. Women were also prominent as lay practitioners.
After the War of 1812, medical schools began to proliferate.
The shift from using midwives to using doctors started among women in
urban middle classes.
A more general decline of women in the field of medicine paralleled social
influences; these stated that women, once married, should assume a strictly
domestic role. The New Democracy did not include women.
1816: René T. H. Laënnec introduced the first crude stethoscope; auscultation
allowed the physician to penetrate behind the externally visible to "see"
into the living. Doctors had previously observed patients; now they examined
1817: Dr. Thomas Ewell of Washington, D.C., proposed to establish
a school for midwives connected with a hospital (such as in Europe) and
sought federal funding. The funding was denied, and the school never came
1825: German immigrants brought homeopathy to America. Homeopathic
medical schools admitted women willingly.
1828: The word "obstetrician" was formed from the Latin,
meaning "to stand before."
1830s and 1840s: "Popular Health Movement" peaked
and remained influential throughout the century. (Health was coming to be regarded
as each person's responsibility.)
Between the period 1820 to 1840, many licensing laws were being
rescinded or abolished.
Sometime during the mid-1800s, some doctors went into "contract
practice," which is actually a primitive form of health insurance.
1847: Elizabeth Blackwell was accepted into the Geneva (New York)
Medical College. She graduated at the top of her class.
1848: The American Medical Association was founded to enforce
standards on medicine as well as its practice.
1848: Dr. Walter Channing of Boston first used ether for childbirth,
for humanitarian reasons.
1848: Gold was found at Sutter's Mill on the American River, transforming
San Francisco into a metropolis almost overnight.
1840-1890: Phase 1 of public health. Period of "empirical environmental
1850-1890: Phase 2 of hospitals. A variety of more "particularistic"
hospitals were formed. These were primarily religious or ethnic institutions
and specialized hospitals for certain diseases or categories of patients.
They were also owned by medical sects, mainly homeopaths. There were a
large number of Catholic immigrants.
1856: The New York Infirmary for Women and Children was founded.
Puerperal (childbed) fever was at epidemic proportions during the 1800s.
The limited training of doctors in the 1800s was not so much an expression
of ignorance as it was a response to economic realities—the limits
of effective demand.
1860: The factory, through the aid of improved means of transportation,
was able to supply the needs of the people for manufactured commodities.
Late 1870s: Phones became available and dramatically reduced the cost of doctors'
visits by making it easier to locate and contact the physician.
1860: The average earnings of physicians put them at lower middle
1860: Abraham Lincoln was elected U.S. president.
1861: The Civil War began in April.
1861: The telegraph was invented.
1863: President Lincoln issued the Emancipation Proclamation on January
1, declaring that slaves in rebellious states, or parts of, were to be
1864: Elizabeth and Emily Blackwell opened a medical college for
women in conjunction with the infirmary.
1865: Confederate Commander-in-Chief Robert E. Lee signed the surrender agreement of the Civil
War. President Lincoln was assassinated April 14.
1869: Transcontinental railroad was finished.
1870s: In a showdown regarding homeopathy, the American Medical Association no longer allowed
physicians who were homeopaths to remain in orthodox societies.
1870: Congress approved a charter for a homeopathic medical society
in Washington, D.C.
1873: Three training schools for nurses were established in New
York. The professionalization of nursing furthered tendencies toward order
Between the 1870s and 1880s, a common support for the restoration of
medical licensing was sought among all the competing groups.
1879: Thomas Edison produced the electric light bulb.
1880: Louis Pasteur demonstrated that the microbial chains of
streptococci he had discovered in 1860 were the major cause of puerperal
1886: American Federation of Labor was formed.
1886: Statue of Liberty was unveiled in New York Harbor.
1888: The American College of Obstetricians and Gynecologists
(ACOG) was formed.
1890: Sherman Antitrust Act was passed.
1891: Andrew Still began teaching the practice of osteopathy in
1890-1910: Phase 2 of public health. First applications of bacteriology
emphasized isolation and disinfecting.
1890-1920: Phase 3 of hospitals. The advent and spread of profit-making
hospitals took place. Operated by physicians singly or in partnership
as well as by corporations, the hospitals' large growth was due in part to the
new potential for profit from surgery.
1890s: Christian Science and chiropractic medicine came into being.
1894: The first cesarean section was performed in Boston.
1895: The X-ray was developed.
Around the Turn of the Century
Economic changes made families less self-sufficient.
Scientific discoveries and the development of more effective treatments
led to increased public acceptance of medicine.
Automobiles and smooth roads made hospital access easier.
Some large city hospitals opened prenatal clinics.
Anesthesia was introduced in the late 1800s and "twilight sleep"
As medical education and care improved, physicians organized to solidify
their status and authority.
Late 1800s: Public hygiene was successfully applied. Key scientific breakthroughs
in bacteriology came about, and new water-sand filtration systems and
regulation of the milk supply cut typhoid fever as well as infant mortality.
Other useful bacteriology occurred in surgery. The advent of antiseptic
surgery sharply reduced the mortality from injuries and operations and
increased the range of surgical work.
Immigration was limited during and after World War I and thus reduced
the supply both of foreign-trained midwives and the number of foreign-born
women, the most loyal clientele of midwives.
Physicians were becoming wealthier and being integrated into middle- and
Prejudice against the intelligence and capability of women, immigrants,
black people and poor people was used to defame midwifery.
Midwives were not in a position of power; they made relatively little
money, were not organized and did not see themselves as professionals.
Vaccines against typhoid and tetanus were developed.
Doctors were among the first to purchase automobiles.
Industrialization and urban life also brought an increase in the number
of unattached individuals living alone in cities. Urban growth led to
higher property values, forcing many families to abandon private homes
for apartments in multi-family dwellings, which limited their ability
to set aside rooms for the sick or those in childbirth.
At the turn of the century, the main field of surgical intervention was
In the early 1900s, medical societies offered to handle malpractice suits
for members. Doctors formed alliances to one another and testified on
behalf of one another. If a doctor did not belong to the medical society,
he had trouble getting insurance.
By 1900, physicians were attending about half the nation's births, including
nearly all births to middle- and upper-class women. Midwives took care
of women who could not afford a doctor.
1900: Horses outnumbered cars 21 million to 8,000.
1900: Less than 5 percent of women gave birth in hospitals.
1901: U.S. Steel, the nation's first billion-dollar corporation,
1903: Orville and William Wright became the first humans to fly.
Between 1880 and 1924, more than 26 million immigrants came to America.
The peak year was 1907, when more than 1.2 million came.
1904: A crisis in hospital finance brought about new management,
new policies and increased contributions from patients.
As more and more doctors became educated, they began to see midwifery
as perpetuating uneducated, indecent ways. They also experienced an increase
in financial rewards.
The railroad industry led in developing extensive employee medical programs
The early 1900s saw the rise of partnerships, group practices and clinics in medicine.
Before 1900, fierce competition and patient-stealing attitudes were prevalent.
After 1900, most women were attracted to hospitals because hospitals could
offer painless birth not available in homebirths.
1904: The appearance of the first maternity clothes—by Lane
1904: The Socialist Party was the first American political party to
endorse health insurance.
1910 on: Phase 3 of public health. New Public Health offered an
emphasis on education in personal hygiene and "the use of the physician
as a real force in prevention" by organizing medical examination
of the entire population.
1910: The Flexner Report revealed that 90 percent of doctors were without
a college education and that most had attended substandard medical schools.
1910: The Carnegie Foundation for the Advancement of Teaching
published Abraham Flexner's critical report on medical education in North
America. Flexner concluded that America was oversupplied with poorly trained
doctors and recommended that most medical schools in operation be closed,
that only the best remain open, and that all that remained open be strengthened
based on the model provided by Johns Hopkins. Flexner singled out obstetrics
as making "the very worst showing."
1912: The Federal Children's Bureau was founded to investigate
mortality in birth and to provide accurate information on the health of
children, among other responsibilities.
President Theodore Roosevelt supported social insurance, including health
insurance, in the belief that no country could be strong whose people
were sick and poor. He was defeated in 1912 by Woodrow Wilson.
1913: Henry Ford developed the moving automobile assembly line,
which pioneered manufacturing systems that turned out every conceivable
product uniformly and efficiently.
1913: The federal income tax was a modest 1 percent on personal income
exceeding $3,000, and 7 percent on incomes above $500,000. Less than 1 percent of the
population had to pay.
1914: Dr. Eliza Taylor Ransom founded a maternity hospital in
Boston's Back Bay and also began the New England Twilight Sleep Association
to force hospitals to offer the procedure.
1914: Twilight sleep was introduced into the United States. Upper-class
women formed "Twilight Sleep Societies." Obstetric anesthesia
became a symbol of the progress possible through medicine.
1915: The Association for the Study and Prevention of Infant Mortality
published a paper in which Dr. Joseph DeLee described childbirth as a
pathologic process. He believed that childbirth was not a normal function
and that midwives had no place in childbirth.
By 1915 there were at least 538 baby clinics in America, five times more
than in 1910, when the National Association for the Study and Prevention
of Infant Mortality was formed.
1915: The American Association of Labor Legislation drafted the
first bill for health insurance. It would pay for medical costs, sick
pay, maternity benefits and a death benefit.
1917: Two developments changed the entire complexion of the
health insurance debate:
- Even though the AMA House of Delegates in June 1917 approved a final report
from its social insurance committee favoring health insurance, this action did
not reflect the sentiment in state medical societies.
- The United States entered World War I in April, many physicians went into the
service, and the AMA closed down its committee on social insurance.
The war proved to be the graveyard of an already faltering Progressive
movement. It diverted attention from social reform, channeled the enthusiasm
for doing good into a crusade abroad, and divided the old Progressives
such as Theodore Roosevelt from the more pacifist and isolationist elements
of the movement.
1918: The United States stood 17th out of 20 nations in mortality
1918: The Maternity Center Association of New York was founded
to provide prenatal care in poor neighborhoods and education of mothers.
In Victorian times, women were thought to be socially "frail"
and tried anything to rid themselves of pain in childbirth.
Until specific cures for puerperal fever were available in the late 1930s,
each woman felt she needed preventive treatment.
Health insurance vanished during the 1920s.
Economic prosperity during the 1920s increased the size of the middle
class, which directed women not to work. Upper- and middle-class women
wanted doctors, not lower-class midwives.
By 1920, doctors believed that "normal" deliveries were so
rare that interventions should be made during every labor to
1920: Radio became a commercial broadcasting medium.
1920: Dr. Joseph DeLee, author of the most frequently used obstetric
textbook of the time, argued that childbirth is a pathologic process from which few
escape "damage." He proposed a program of active control over labor and
delivery, attempting to prevent problems through a routine of interventions. DeLee
proposed a sequence of medical interventions designed to save women from the "evils"
that are "natural to labor." Specialist obstetricians should sedate women
at the onset of labor, allow the cervix to dilate, give ether during the second stage
of labor, cut an episiotomy, deliver the baby with forceps, extract the placenta,
give medications for the uterus to contract and repair the episiotomy. His article
was published in the first issue of the American Journal of Obstetrics and Gynecology.
All of the interventions that DeLee prescribed did become routine.
Maternal mortality reached a plateau, with a high of 600 to 700
deaths per 100,000 births, between 1900 and 1930.
By the 1920s, the medical profession had won stronger licensing laws
and turned into support of its powers the threats to its position that were made by hospitals, drug
manufacturers and public health. The medical profession controlled
corporations' and mutual societies' entry into health services and also succeeded in controlling the development of technology and organizational
forms as well as the division of labor. The medical profession helped shape the medical system so
that its structure supported professional sovereignty instead of undermining
American workers, mainly working-class families, spent considerable money for "industrial" life insurance policies to cover
funerals and expenses of a final burial ($183 million in 1911).
1920: Prohibition went into effect.
1920: Woman suffrage and the right of women to vote were big
1921: The Miss America Pageant was created.
1921: The Sheppard-Tower and Infancy Protection Act became a
federal law. It encouraged states to make their own plans to improve maternal
and child health and provide funds to train people who would be needed
to implement the plans.
1921: Thirty percent to 50 percent of women gave birth in hospitals.
1925: Mary Breckenridge founded The Frontier Nursing Service of
The first five nurse-midwifery schools were developed to meet the needs
of special populations, which were isolated by geography, poverty, language,
culture or race.
1929: Old-age pension laws began to be passed.
1929: The AMA lobbied against the Sheppard-Tower Act, and Congress
allowed it to expire.
1929: In October the stock market crashed, launching the Great
Health examiners almost uniformly showed that very few people were healthy
and normal, which helped to foster the belief that Americans needed more
medical care and health supervision.
1930: The American Board of Obstetricians and Gynecology was established.
During the 1930s, general practitioners and specialists had a division
of labor. Specialists such as obstetricians sought to achieve ascendancy over the non-physician
specialists, such as midwives, in their specialized areas. Specialists
also sought to impress upon the general practitioner the limit of his or her
Blue Cross insurance plans began to emerge in the 1930s. These plans were single-hospital-based programs and, later, community-based programs. Hospitals agreed to provide services
regardless of the remuneration they would receive. This took the place
of capital funds that other insurance companies needed to organize and
run their businesses.
1932-1938: A terrible drought set in and became the worst agricultural
disaster in American history.
1932: The MCA began to train qualified public health nurses in
1932: Unemployment insurance was introduced.
1933: Congress repealed Prohibition.
1933: The White House Conference on Child Health and Protection
issued a report stating that maternal mortality had not declined between
1915 and 1930, despite the increase in hospital delivery, the introduction
of prenatal care and more use of aseptic techniques. The number of infant
deaths from birth injuries actually increased by 40 percent to 50 percent from 1915 to 1929
for one of two reasons: either women received inadequate or no prenatal care
or excessive intervention took place and was often improperly performed.
1935: Thirty-seven percent of births occurred in hospitals.
1935: Franklin D. Roosevelt instituted the Social Security Act.
1937: Japan made war on China.
1937: Single hospital plans had 125,000 subscribers, just as the
year before, whereas the "free-choice" plans went to 800,000
1938: By this time, doctors used "twilight sleep" in
1939: Hitler invaded Poland.
1939: Fifty percent of all women and 75 percent of all urban women delivered
During World War II, more than 3 million women were recruited for war-related
While President Harry Truman lobbied hard for a national health insurance program
in the 1940s, the AMA lobbied hard against it, calling it "socialized
medicine," and turned the polls completely around from a plan favored by the American people
to one that was vanishing.
The AMA campaign against nationalized medicine cost $1.5 million. At the
time it was the most expensive lobbying effort in American history.
1940: Private insurance companies had about 3.7 million subscribers,
while Blue Cross had more than 6 million.
1941: The Japanese attacked Pearl Harbor on December 7, and the United
States entered World War II.
1944: Dr. Grantly Dick-Read's book on natural childbirth was published
in the United States.
1945: The atomic bomb was detonated over Hiroshima on August 6, and
a second bomb was dropped on Nagasaki on August 9. Japan surrendered on
1946: The first digital computer was unveiled in February at the University
The baby boom began in 1945 and reached its height in 1947, but it continued
for another 17 years. The baby boom placed in high demand goods and services associated
with the boom, with the purchase of a home being the largest expenditure.
1948: The Kinsey Report—Sexual Behaviors in the Human Male
and Sexual Behaviors in the Human Female—were published,
bringing to light many topics that had long been taboo.
In the post-World War II era (late 1940s), workers' unions began bargaining
for health insurance, expanding greatly the scope of coverage as well
as employers' contributions.
1941-1951: The federal budget for medical research rose to $76 million
from $3 million. Total national expenditures went to $181 million
from $18 million.
1950: America became increasingly anti-Communist, which channeled
into opposition to nationalized health insurance. Other countries did not take this
stance and took part in the steady expansion of health insurance to all
sectors of their society.
1950s: Sister Mary Stella, CNM, introduced the concept of "family-centered
1950: Eighty-eight percent of births occurred in hospitals.
1950: The first charge card, The Diners Club, was produced.
1950: The Korean War began.
1952: The Midwifery Section of the National Organization for Public
Health Nursing developed a philosophy that emphasized pregnancy and childbearing
as a normal process, as well as a family-centered event in growth and
1954: Brown vs. Board of Education ruled against segregation in
1954: The polio vaccine was developed.
1955: The American College of Nurse Midwives (ACNM)
1955: Columbia-Presbyterian-Sloan Hospital in New York City became
the first mainstream medical institution to open its doors to nurse-midwives.
Between 1950 and 1970, the medical work force increased to 3.9 million people from 1.2
million people. National health care expenditures grew to $71.6 billion (7.3 percent of gross national product) from $12.7 billion (4.5 percent of gross national product).
1956: La Leche League
In the postwar period, considerable money was invested in medical
research by private groups, government, universities and insurance
The infusion of money into research and training programs created new
opportunities for medical schools. During the 1940s the average income
of medical schools tripled to $1.5 million per year from $500,000 per year. By
1958 it was up to $3.7 million, and by 1968 it had reached $15 million.
Medical schools became sprawling, complex organizations that now saw
their missions as threefold: research, education and patient care.
1950s: Specialization in an area of medicine took a dramatic jump.
Dr. Robert Bradley and Dr. Ferdinand Lamaze were introduced.
The Kennedy administration took up the cause of "community care"
and turned it into a major federal program in the 1960s.
1960: Ninety-seven percent of births occurred in hospitals.
1960s: The civil rights movement brought attention to the realities
of poverty and racial injustice.
1960: The birth control pill became available. President John F. Kennedy and Vice President Lyndon B. Johnson
were at the forefront in civil rights legislation.
1960: Continuous electronic fetal monitoring was introduced.
1960: The Children's Bureau began to fund selected nurse-midwifery
1960: The Food and Drug Administration issued the birth control pill for prescription in the United States.
Feminine Mystique, a groundbreaking book by Betty Friedan, was published.
Friedan held that women should have choices apart from the destiny society had set. Gender stereotypes began to crumble as women began to organize.
1963: The march on Washington calling for racial justice took
1963: President Kennedy was assassinated November 22.
1964: The Civil Rights Act became law.
1965: The War in Vietnam began to escalate.
1965: President Johnson on July 30 signed into effect Medicaid and the Medicare
1966: One-half of U.S. men and one-third of U.S. women smoked.
The U.S. surgeon general issued the statement that the habit was a major
cause of lung cancer, emphysema and heart disease.
1968: Dr. Martin Luther King was assassinated in April.
1969: Man set foot on the moon for the first time July 16.
1969: The Woodstock Festival occurred.
Adolescent (teen) pregnancy was on the rise and of "epidemic"
proportions until the mid-1970s.
1965-1975: The use of medical services by the poor increased sharply.
President Lyndon Johnson continued the war on poverty that President Kennedy had initiated just before his death.
1960s and 1970s: Government-funded projects to increase health
care for the poor were on the rise. This gave all mid-level health care workers a
tremendous increase in jobs and opportunities
In the early 1970s, the sense of crisis in health care was accompanied
by considerable optimism about the possibilities for successful reform.
By 1970, public officials began to regard the rising costs of health
care as too high and to doubt that the investment was worth the return
1970s and onward: Doctors made more money per hour in a hospital
visit than they did in an office visit.
1970: Four students were killed by the Ohio National Guard during a protest over the Vietnam War at Kent State University.
1970: Only about 9 percent of medical students were women. By the end
of the 1970s, this had risen to 25 percent.
1970: Federal government began to support the development of
family planning services for the poor.
1970: National Certification in nurse-midwifery educational
programs was in place.
In the 1970s, the three branches of the U.S. military service began to
train and use nurse-midwives.
1970-1971: HMOs were created.
1971: The Farm was started in Tennessee by Stephen and Ina May
Gaskin, and Ina May began to attend births. In 1975, she published her book, Spiritual
1971: The Birth Center of Santa Cruz was started.
1972: The American Hospital Association adopted a Patient's
Bill of Rights.
1973: The ACNM stated, "The preferred site for childbirth
because of the distinct advantage to the physical welfare of mother and infant is
1973: Roe vs. Wade guaranteed the right to terminate pregnancy.
1973: On January 27, after 10 years of U.S. involvement in Vietnam,
the cease-fire took place.
1973: The Watergate hearings were under way.
1973: The energy crisis occurred.
1974: President Richard Nixon resigned under threat of impeachment.
The incentives that favored hospital care promoted the neglect of ambulatory
and preventive health services. The incentives that favored specialization
also caused primary care to be neglected.
The concept of "health care as a matter of right, not privilege"
captured the spirit of the time better than any other single idea.
Concerns of the new health rights movements included such rights in health
care as the right to informed consent, the right to refuse treatment,
the right to see one's own medical records, the right to participate in
therapeutic decisions, and the right to due process in any proceeding
for involuntary commitment to a mental institution.
A movement developed to "deinstitutionalize" the dependent
and "demedicalize" critical life events, such as childbirth
and dying. The interest in hospices and homebirths derived, at least in
part, from a desire to escape professional dominance as well as from the
desensitizing environment of the hospital.
In the early 1970s, women's groups also began learning gynecological
self-care and encouraging a revival of lay midwifery. Feminists argued
that medical care needed to be demystified and women's lives demedicalized.
They maintained that childbirth is not a disease and that normal deliveries
do not require hospitalization and the supervision of an obstetrician.
The conflict over homebirth proved to be one of the most bitter between
the medical profession and the women's movement. While no state forbade
homebirth, ACOG actively discouraged it. Doctors who participated in
homebirths by offering backups in emergencies were threatened with loss
of hospital privileges and even their medical licenses.
1974-1975: A severe economic recession, accompanied by soaring
inflation, arrested new initiatives to expand medical care and other social programs.
After 1974, the combined impact of the recession and inflation hopelessly
stalled the movement for national health insurance.
1975: The Birth Collective at Freemont Women's Clinic in Seattle
1976: The Division of Nursing began to fund nurse-midwifery
Consumer criticism of aggressive medical management of childbirth occurred
within the social context of the 1960s and 1970s, including the civil
rights movement, the women's movement, the consumer movement, the anti-war
movement, and the back-to-nature and health food movement.
1979: The FDA convened a special meeting to discuss results
of a large national study that found lingering behavior and motor deficits in children
whose mothers had received anesthesia in large doses of analgesics, including Demerol.
This press increased the interest in natural childbirth and boosted the homebirth
and midwife movements.
1980: The ACNM developed guidelines for establishing "alternative"
birthing services and dropped a negative homebirth statement (originally approved
in 1971) in favor of a statement that endorsed practice in all settings.
By 1980, the primary concern about medical and other health care had
shifted from access and quality to an overriding concern about costs.
1981-1982: AIDS came to the attention of the medical world.
1982: The Midwives Alliance of North America (MANA)
began. One-third of its members were CNMs, and the rest were other types of midwives.
Insurance (liability) coverage declined rapidly for CNMs from 1982 to
1985, with some companies totally withdrawing from coverage or making
1983: The Federal Trade Commission intervened in a CNM-doctor
case and negotiated an agreement that prohibited the insurance company from any
form of discrimination against doctors who collaborate with CNMs.
1983: The National Association
of Childbearing Centers was established.
1985: The AMA set out to create legislation and regulation for all
non-physician health care workers that would not allow these workers to practice independently.
1987: The INF treaty, eliminating nuclear missiles, was adopted.
The American Academy of Family Physicians (AAFP) opposed nurse-midwifery
and issued formal statements to that effect in 1980, 1990 and 1993. AAFP
stated the belief that all nurse-midwives should work non-independently
and that all payments should go through the physician.
During the 1980s, there was a widening and deepening sense of crisis
regarding the country's ability to provide adequate and effective maternity
and other reproductive health care for all of its women. Racial and ethnic
minority women, rural women, and women living in poverty and social distress
were particularly likely to have limited access to effective care.
Securing adequate and affordable professional liability insurance was the
most demanding challenge faced by nurse-midwives during the 1980s.
During the late 1980s, Congress enacted legislation to make Medicaid
available to more women and also required states to make Medicaid-eligible
women's access to obstetric care equal to that of other women. Also, most
states began to pay more for maternity care.
In the first half of the 1990s:
- Physicians who were once disinterested in taking care of poor, pregnant women
became more willing to do so as Medicaid increased fees paid for services
and made it easier to obtain these fees.
- In areas where a large proportion of people were enrolled in Managed Care
Organizations (MCOs), midwives who were not part of the MCOs became less accessible
to women who wanted midwifery care.
- For a woman to have access to midwifery care, her entire family might have
to enroll in an organization that provided it.
- Directors of large MCOs tended to focus on the bottom line—how to cut costs
—and many did not understand the nature and role of midwifery.
- Although all MCOs were required to offer maternity care, some smaller ones
discouraged CNMs because they attracted pregnant clients and because families during
childbearing use health care more.
- Small MCOs needed generalists and were encouraging family practitioners to
- Some birth centers were bought out by MCOs, which threatened to compromise
their autonomy as well as the type and quality of care they provided.
1992: The governor of New York signed a new Professional Midwifery Practice Act
into law in July. The act defined midwifery as a profession with a specific scope
of practice and called for a board of midwifery to regulate the profession.
1993: The first randomized, controlled trial to observe the
effects of epidural anesthesia was published. The investigators stopped the study
after they analyzed the data from the first group and saw the high rate
of cesarean section. They determined it would not be ethical to continue the study
and reported their findings.
1993: Programmers at the University of Illinois released software
that enabled anyone to surf the World Wide Web.
1993: The ACNM obtained a stable and long-term professional liability
Some insurance companies refused to write policies for physicians who
worked with midwives—or charged physicians higher premiums if they did—thus
imposing restrictions and requirements that limited and burdened the practice.
Primary-care providers were on the increase, as managed-care plans took
over the health insurance industry.
1994: At least 1 million people lost their health care coverage
after the collapse of President Bill Clinton's plans for universal health care.
1994: The North American Registry of Midwives (NARM)
offered its first written examination to test the knowledge needed for safe, beginning-level,
direct-entry midwifery practice to implement a process to certify direct-entry
midwives. It expanded the process to include entry-level midwives in 1996.
The managed care plans created turmoil for low-income and Medicaid women.
By moving women from Medicaid programs into private hospitals and managed
care plans, the plans removed these women from the very programs that
were designed to meet their specific needs.
The move to managed care resulted in termination of many special programs
that used nurse-midwives to provide care to pregnant women with special
CNMs in almost every state practiced under different laws than those
that affected other kinds of midwives.
The number of jurisdictions that grant prescriptive authority to CNMs
increased to 31 in 1995 from 14 in 1984.
Federal law required all state Medicaid programs to pay for care provided
1995: The AMA House of Delegates added a statement that "The
physician is responsible for the supervision of Nurse Practitioners and other advanced
practice nurses in all settings."
1996: A coalition of American maternity care organizations created
Ten Steps for a Mother-Friendly Childbirth Initiative.
1997: Pathfinder (a camera) on July 4 landed on Mars able to take
vibrant pictures as well as analyze data on the planet.
HMOs were leaders in the use of midwives.
Legal status of direct-entry midwives is a state-to-state status.
- Despite many new, favorable laws, direct-entry midwifery is still illegal in
- Licensing standards, where they exist, vary from state to state, and there are
no mandatory national standards for entry into practice. As a result, there is
no clear definition of a "midwife" as a person who has met widely accepted
educational and competency standards.
- The new MEAC and NARM processes are competency based; neither requires completion
of a specified number of years of formal professional education or requires an
- Americans generally associate an "apprenticeship" with preparation
for a craft or trade, rather than a profession.
- The MEAC/NARM accreditation and certification processes are new, and the examination
is an improved, strengthened version of an earlier examination, which was known
by the same name and did not require a positive response.
- There is very little reliable data about direct-entry midwives and their practice.
It is impossible even to state with accuracy and confidence either the number
of direct-entry midwives who are practicing or the number of births they attend.
- Direct-entry midwives' sharp criticism of the medical profession combined with
their physical isolation from the mainstream health care system has made it difficult
or impossible for many of them to acquire adequate medical backup.
The United States provides the world's most expensive maternity care
but has worse pregnancy outcomes than almost every other industrialized
Midwives are attending more births—5.5 percent in 1994, compared with 1.1 percent
The cesarean section rate is falling, from 25 percent in 1988 to 21 percent in 1995.
The use of forceps is declining, from 5.5 percent in 1989 to 3.8 percent in 1994.
Labor was induced in 14.7 percent of women in 1994, up from 9 percent in 1989.
Eighty-five percent of women had electronic fetal monitoring in 1994, up from 68 percent in
Adrian Feldhusen is a New Hampshire Certified Midwife and CPM serving
southern New Hampshire and northern Massachusetts. She owns The Birth
Cottage, a free standing birth center. Adrian has a bachelor of science
degree in community and human services, with a concentration in maternal
and perinatal health, through the State University of New York. In 1992
she began her lifelong quest into midwifery. Her services include
full-scope midwifery and homebirth, birth center birth, counseling for
miscarriage and loss, breastfeeding consultation, and well-woman services.
Sources used to complete this time line:
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