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 eternal judgment.

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 sick.

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 and cathartics.

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 them.

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 to be.

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 sanitation."

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 class.

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 "forever free."

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 and cleanliness.

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 fever.

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 Missouri.

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" in 1914.

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 upper-class societies.

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 the abdomen.

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, was started.

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 around 1900.

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 Bryant—took place.

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:

1. 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.
2. 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 rates.

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.

The 1920s

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 prevent trouble.

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 it.

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 issues.

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 Hyden, Kentucky.

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 Depression.

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.

The 1930s

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 abilities.

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 midwifery.

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 from 200,000.

1938: By this time, doctors used "twilight sleep" in all deliveries.

1939: Hitler invaded Poland.

1939: Fifty percent of all women and 75 percent of all urban women delivered in hospitals.

The 1940s

During World War II, more than 3 million women were recruited for war-related jobs.

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 August 14.

1946: The first digital computer was unveiled in February at the University of Pennsylvania.

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.

The 1950s

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 maternity care."

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 development.

1954: Brown vs. Board of Education ruled against segregation in public education.

1954: The polio vaccine was developed.

1955: The American College of Nurse Midwives (ACNM) was formed.

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 was founded.

In the postwar period, considerable money was invested in medical research by private groups, government, universities and insurance companies.

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 1960s

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 education programs.

1960: The Food and Drug Administration issued the birth control pill for prescription in the United States.

1963: The 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 place.

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 Law.

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

The 1970s

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 in health.

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 Midwifery.

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 the hospital."

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 began.

1976: The Division of Nursing began to fund nurse-midwifery education programs.

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.

The 1980s

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 it expensive.

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.

The 1990s

In the first half of the 1990s:

1. 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.
2. 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.
3. For a woman to have access to midwifery care, her entire family might have to enroll in an organization that provided it.
4. 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.
5. 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.
6. Small MCOs needed generalists and were encouraging family practitioners to re-enter obstetrics.
7. 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 program.

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 needs.

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 by CNMs.

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.

Barriers Today

1. Despite many new, favorable laws, direct-entry midwifery is still illegal in many states.
2. 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.
3. 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 academic degree.
4. Americans generally associate an "apprenticeship" with preparation for a craft or trade, rather than a profession.
5. 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.
6. 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.
7. 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 country.

Midwives are attending more births—5.5 percent in 1994, compared with 1.1 percent in 1980.

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 1989.

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:

• The Editors of Time-Life Books. (1998, Nov.). Events that Shaped the Century. Time Life.
• Rooks, Judith Pence. (1999, May). Midwifery and Childbirth in America. Temple University Press
• Starr, Paul. (1984, May). The Social Transformation of American Medicine. Basic Books.
• U.S. News and World Report. (1973). 200 Years: A Bicentennial Illustrated History of the United States.
• Wertz, Richard and Dorothy C. (1989, Sept.). Lying-In: A History of Childbirth in America. Yale University Press

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