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Midwifery Regulation in the U.S.From: Cheri Van Hoover (cherivh@xdcr.com)Mon Nov 21 10:11:38 2005
Gail, this is a very complex subject. I suggest you get a copy of "Midwifery and Childbirth in America" by Judith Pence Rooks. It is an excellent book which explains exactly how midwifery practice evolved in the U.S. and how it is regulated, as well as discussing the challenges to safe and effective care posed by our system (as Lynn so elegantly described). In brief: 1) Midwives delivered almost all the maternity care in the earliest days of this country. This was true in Colonical times (see "A Midwife's Tale" by Laurel Ulrich, which won a Pulitzer for history/nonfiction). It continued to be true for most of the 1800s, with some rise in medical care for birth (especially among the upper classes) after the introduction of anesthesia for birth. Most immigrants to this country used the services of midwives from their homelands. The educational levels and skills/safety of these midwives varied widely. 2) During these years medical practice and midwifery practice were largely unregulated. There were few formal schools of medicine and most practicing physicians were apprentice-trained. 3) Around 1900 physicians began to push for self-regulation and formal education for doctors. The AMA was born. One of their first actions was to push for the elimination of midwives on the basis that we were dirty, ignorant, unsafe, and female. Most of all, we were economic competitors. An organized campaign by physicians to legislate midwifery out of existence was begun and by 1920 it was quite successful. 4) Social changes in the U.S. caused women to seek hospital birth, reject breastfeeding, and glamorize the cause of "Twilight Sleep" for childbirth analgesia. Societies were formed promoting its use. 5) Midwifery and home birth remained in isolated pockets, mostly amongst groups of women physicians did not choose to serve because they were poor or were oppressed minorities. Most of these midwives were not formally educated and were members of these oppressed minorities. 6) In 1925 Mary Breckinridge (granddaughter of a Vice President of the U.S./Secretary of War for the Confederacy) introduced the British model of nurse-midwifery into the hill country of Kentucky. She and the small group of British nurse-midwives she brought to the region reduced maternal and infant mortality by some astonishing number (I'm doing all this without my reference materials at hand, so can't give you statistics). There are many personal and social reasons why she chose the British nurse-midwifery model. These can be read about in Rooks' book or in Mary Breckinridge's autobiography, "Wide Neighborhoods." 7) Breckinridge's wealth, social status, and remarkable organizational skills led to the adoption of her model in many other areas and the eventual formation of the American College of Nurse-Midwifery. Through the legal and political actions of this group, nurse-midwifery became legal in all 50 states and the practice of this profession spread. These midwives are known as Certified Nurse-Midwives (CNMs). 8) The practice of midwifery without formal education never entirely disappeared, although these midwives mostly practiced outside the law. In a few states these midwives could register to provide care legally. During the 1960's, when the natural foods and holistic health and back to the land movements occured, the number of these midwives (known then as "lay" midwives, now usually called "direct-entry" midwives) proliferated. Some states passed laws allowing these midwives to practice legally if they completed formal educational paths available within those states. These "licensed midwives" (LMs) practice legally in the states where this is allowed. They are also "direct-entry" midwives because they went directly into midwifery, without a nursing education. 9) The Midwives Alliance of North America (MANA, an organization of direct entry midwives) developed a certification process in the 1990s. If a midwife completes certain practical experience requirements and passes their exam, she can be certified as a Certified Professional Midwife (CPM) through MANA. Some states recognize this credential, but most do not. 10) In response to strong feelings amongst many of their members that nursing is not a necessary prerequisite to midwifery practice, the American College of Nurse-Midwives (ACNM) opened the doors of some of their midwifery education programs to non-nurse applicants about a decade ago. These non-nurse graduates of accredited nurse-midwifery programs are known as Certified Midwives (CMs). This has not proven to be a popular or hugely successful program, as not all states will recognize this credential and these graduates are largely restricted to out of hospital birth. 11) Many CNMs do homebirths, but the vast majority practice in hospital. This is because of the political and legal climate in this country, which others have described quite well. This is a very long answer to a simple question, but the history and status of midwifery in this country is complex. It is also very simple. It all comes down to money, power, and politics.
-- Cheri Van Hoover, CNM, MS Faculty, Midwifery Institute at Philadelphia University
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