Origins of Nurse-Midwifery in the United States and Its Expansion in the 1940s

Early Tewntieth Century Origins: Frontier Nursing Service and Maternity Center Association

During the late 19th and early 20th centuries, the United States experienced massive immigration of peoples from southern and eastern Europe. Packed into densely populated urban areas, men, women, and children worked long hours in unsafe factories, packing houses, and tenements. Conditions facing these immigrants became the object of social reformers and public health nurses who set out to Americanize immigrants, reform crowded ghettos, improve working conditions, and reduce poor health outcomes.

Of specific concern to health reformers were rates of maternal and infant mortality, which were higher than comparable rates in 13 European industrialized countries. Between 1900 and 1930, maternal mortality in the United States ranged from 85 to 67 per 10,000 live births compared to maternal mortality rates of 48 to 44 per 10,000 in England and Wales and 23 to 33 per 10,000 in the Netherlands, where midwives managed most of the births (Figure 1). ^[7] Likewise, between 1900 and 1910 infants in the United States died at higher rates than in 21 European nations.^[8] Between 1915 and 1933, neonatal mortality in the United States ranged from 44 to 34 per 1,000 live births and infant mortality from 99.9 to 58.1 per 1,000 live births.^[9] At a time when traditional midwives managed 50% of all births, reformers blamed these high mortality rates on European immigrant midwives who cared for their country women and on African American midwives who provided most of the health care received by southern African American women.^[1]

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Maternal mortality rates in selected countries, 1900-1940.

Obstetricians seeking to develop the medical specialization of obstetrics^[4,5,6] and public health nurses aspiring to establish a specialty in midwifery joined in a campaign to eliminate traditional midwives. Medical, public health, and nursing journals published articles accusing immigrant and African American midwives of being ignorant, dirty, and dangerous (these descriptors were believed as fact, widely used during this campaign, and appeared in print as late as the 1980s)^[1] in an attempt to restrict and then eliminate traditional midwifery practice. This was a racist campaign based on the now discredited theory of eugenics, which held that traits such as intelligence, honesty, and cleanliness were racially inherited and that women, African Americans, and foreign immigrants were deficient in these qualities.^[10]

The campaign ignored data that showed immigrant and African American midwives provided good care. Statistics available in the 1920s^[11,12] and 1930s^[13] demonstrated significantly better outcomes in terms of maternal mortality among populations of women attended by both African American and immigrant midwives than statistics from populations attended by physician providers ( Table 1 and Table 2 ). This campaign to eliminate the traditional midwife has been extensively described by Kobrin,^[6] Litoff,^[5] Brickman^[4] and Dawley^[1] and is not further reviewed here.

Several early 20th century public health nursing leaders active in the campaign to eliminate traditional midwives shared a vision of educating U.S. nurses in midwifery. They included Carolyn Conant van Blarcom, CNM, best known for her early obstetric nursing textbook^[14] and for her efforts to combat neonatal blindness; Lillian Wald, RN, founder of Henry Street Settlement in New York City and the specialty of public health nursing; Mary Beard, RN, a pioneer in the development of prenatal care and advocate for nurse-midwifery^[1,15]; and Mary Breckinridge, CM, founder of the first nurse-midwifery service in America. Their mission was to decrease maternal and infant mortality, and in the process they hoped to combine public health prenatal nursing care with the practice of midwifery to create a new specialty: nurse-midwifery.

In 1911, Wald and van Blarcom^[16] introduced a motion at the American Association for the Study and Prevention of Infant Mortality to educate nurses in midwifery. After a year of debate, the motion failed, but some public health maternity nurses, who found themselves delivering babies at home when physicians arrived too late, continued to press for education in midwifery.^[1,17,18] In 1923, Maternity Center Association (MCA), under the leadership of Hazel Corbin, RN, and Ralph Lobenstine, MD, attempted to open a midwifery educational program for nurses in conjunction with the Bellevue Hospital Training School for Midwives. This effort failed. First, MCA was unable to attract interest in such a course among state public health administrators. Second, the New York City Commissioner of Welfare opposed the project, reflecting a fear among physicians that well-educated nurse-midwives would be harder to eliminate than immigrant and African American practitioners.^[1]

About this same time, Mary Breckinridge decided that midwifery provided excellent care and support for pregnant women and new mothers. She first encountered nurse-midwives while working as a volunteer in post-World War I France, and she came to believe midwifery was the "logical response to the needs of the young child in America."^[19] She argued that a successful demonstration of the practice would be the best route to introduce and expand nurse-midwifery at home.^[19,20]

Returning to the United States from France in 1921, Breckinridge embarked on a systematic approach to open a nurse-midwifery service. She conducted a survey of maternal and child health needs and the practices of traditional midwives in Leslie County, Kentucky.^[19,20] She also studied public health nursing at Columbia's Teachers College where she had contact with nurses from MCA and Bellevue who were trying to establish midwifery education for nurses in New York City.

Between 1921 and 1923 Breckinridge was preparing to introduce nurse-midwifery in the United States while MCA was working to establish a nurse-midwifery educational program. When the attempt to educate nurses in midwifery at Bellevue failed, Carolyn Conant van Blarcom, who had midwifery contacts in England, helped Breckinridge obtain a place in an English midwifery school. After becoming certified by England's Central Midwives Board, Breckinridge returned to Hyden, Kentucky, in 1925 where, as a Certified Midwife, she began her life's work; establishing Frontier Nursing Service (FNS) with the avowed purpose of improving the health of children in the Appalachian mountains of Kentucky. Soon Freda Caffin, CM, and Edna Rochstroh, CM, two MCA public health nurses, followed Breckinridge to England, became Certified Midwives, and returned to practice at FNS.^[19,20]

In pursuit of her goal to use FNS as a stimulus for other nurse-midwifery services, Breckinridge enlisted the help of Louis Dublin, statistician for Metropolitan Life Insurance Company, to study maternal and neonatal outcomes. Over the years, Dublin reviewed the first 4,000 (1925-1940) and the 10th thousand (1952-1954) confinements at FNS. The results were impressive: nurse-midwives lost significantly fewer mothers and babies compared with figures for surrounding Kentucky counties and for the United States as a whole.^{[21,22,23,24,25]} Following Breckinridge's plan, these excellent outcomes serving the rural poor would later be cited many times over by those seeking to introduce nurse-midwifery care as evidence that it would be safe and effective in other poor and underserved communities.

Several years after the 1925 introduction of nurse-midwifery in Hyden, Kentucky, MCA once again decided to open a midwifery educational program for nurses in New York City. This time they were successful. Public health nurses who provided prenatal care and support during labor and delivery increasingly found themselves alone with laboring women at the moment of birth. As a result, there was more interest in an educational course on midwifery from nurses both within the National League for Nursing Education and the National Organization for Public Health Nurses. In fact, in 1927 a joint committee of the two organizations began to draft plans for such a course and to examine state laws on midwifery practice.^[26,27,28]

MCA received support from several physician members of their board. Benjamin Watson argued, "...maternal mortality...would be materially reduced if the practice of obstetrics was in the hands of thoroughly trained midwives...^[29] Ralph Lobenstine MD, and George Kosmack, MD, were also strong supporters. After Lobenstine arranged hospital backup, MCA moved ahead with plans to start a nurse-midwifery home birth practice and an educational program.^[30] Mary Breckinridge lent her support by joining MCA's Board and sending an FNS nurse-midwife, Rose McNaught, CM, to MCA as America's first nurse-midwife educator.^[17] The home birth practice, which mainly served poor immigrant and African American women, opened in 1931 under the direction of Hattie Hemschemeyer, CNM, and the educational program opened a year later with Hemschemeyer a member of the first graduating class.

There were differences in the way care was structured at FNS and MCA, differences that responded to the demands of location and level of physician concern. In Hyden, nurse-midwives provided prenatal care in rural outposts. They traveled to homes by horseback to manage labor and birth. This level of independence was accepted by the limited number of local physicians, to ensure safe patient care.^[19,20] However, in New York City, there was an abundance of obstetricians worried about competition. At MCA, nurse-midwives traveled to homes for labor and birth by subway and provided prenatal care in a central clinic. Women cared for by the nurse-midwives were first seen by a physician and then approved for nurse-midwifery services. According to MCA's protocols, physicians were to review charts and write orders after each visit. They were to be called on a regular basis from the home to provide orders for the nurse-midwives' care during labor and birth.^[30,31]

There were also differences in how each service obtained funding. When Mary Breckinridge returned from England, she met with Mary Beard who was working at the Rockefeller Foundation. Beard tried and failed to help Breckinridge obtain Foundation funding. Instead, Breckinridge relied on family connections to develop a network of support groups across the country, which raised private funds to support FNS.^[19,20] Mary Beard was more successful in securing Rockefeller funding for MCA. She was able to arrange Foundation funding for tuition and living expense stipends for 12 of the first 25 public health nurses attending MCA's Lobenstine Midwifery School between 1932 and 1936.^{[32,33,34,35]} Furthermore, between 1920 and 1937, the Rockefeller Foundation donated funds for the support of the East Harlem Nursing and Health Service, where nurse-midwives provided prenatal care.^[36] Both undoubtedly went a long way to cover expenses of the educational program and midwifery practice. The indirect financial support for MCA from the Rockefeller Foundation, which came through its China Board, funded the education of nurse-midwives who held leadership positions in the Children's Bureau and state health departments. In these positions, they were able to further the profession's expansion despite Rockefeller corporate policy, which did not support direct funding for nurse-midwifery practice.^[1,35]

During the 1930s, some nurse-midwifery graduates from MCA became maternity consultants in health departments throughout the South, Northeast, and Midwest where they provided prenatal care and identified, supervised, and registered traditional African American midwives. Others obtained administrative positions in hospital obstetric services, where they made hospital birth more woman and family centered.

J Midwifery Womens Health. 2003;48(2) © 2003 Elsevier Science, Inc.

Cite this: Origins of Nurse-Midwifery in the United States and Its Expansion in the 1940s - Medscape - Mar 01, 2003.