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

Expansion of Education and Practice 1940-1950

A demand for nurse-midwifery care emerged in the immediate aftermath of World War II. Initially, workforce needs were focused on provision of care to poor and working class women, but by the late 1940s, middle class women demanded more involvement in their childbearing experience and started a movement that set the stage for major advances. The rest of this article focuses on expansion of nurse-midwifery practice between 1940 and 1950.

First, there was a revolution in payment for health care during the 1940s, which increased demand for all providers of maternity care ( Table 3 ). In 1940, only 9% of the population had third-party coverage for hospitalization. In 1943, faced with an increase in young servicemen's families who did not have financial means to purchase adequate pregnancy related care, the federal government instituted the Emergency Maternity and Infant Care program (EMIC). This program paid for prenatal and postpartum care, hospital delivery, and infant care through the first year of life for servicemen's wives and newborns. Before the program ended in 1946, over a million women and infants who received care under EMIC experienced the benefits of health insurance, and many who might have delivered at home were introduced to hospital obstetric care.^[37]

Second, during the war, labor unions were more successful in negotiating hospital insurance for workers. Twenty-four percent of people in the United States had hospital insurance in 1945, and by 1950 this number jumped to 50%.^[37]

Third, a postwar boom in hospital construction followed passage in 1946 of Hill-Burton federal legislation that provided funds for hospital construction.^[38] Increased construction of hospital beds across the country was one factor that encouraged women to birth in hospitals in rural and southern communities. However, education of physicians had not geared up to meet these new demands, resulting in a shortage of obstetrician/gynecologists and thus a potential for expansion of nurse-midwifery.^[39]

Beginning in 1940 and continuing for the next 10 years, nurse-midwives established new educational programs, clinical practices, and institutions for the practice of nurse-midwifery. The profession responded to unmet needs of women for maternity care and to pressure from women seeking family-centered birth alternatives.

The Children's Bureau was particularly interested in educating nurse-midwives to oversee and replace the apprentice-educated "granny," who was still delivering a large number of African American women in the South. The Children's Bureau provided consultation to the Medical Mission Sisters as they designed their midwifery service and school in Santa Fe, New Mexico, and gave partial funding for two educational programs in the South designed to educate African American nurses in midwifery.^[40]

In New Orleans, Louisiana, Flint Goodrich Hospital opened an educational program in association with Dillard University. This program was directed by Kate Hyder, CNM. Hyder studied midwifery at MCA with funding from the Rockefeller Foundation. Lasting only 1 year, 1942-1943, Flint Goodrich graduated two African American nurse-midwives. One of the graduates, Deola Lange Cyrus, CNM, graduated from Flint Goodrich School of nursing 24 years earlier and earned a certificate in public health nursing prior to entering the nurse-midwifery program. Her work with the Louisiana State Department of Health, providing antepartum and postpartum care, as well as supervising apprentice educated midwives, began in 1927 and continued until 1958.^[41,42]

The second educational program for African American nurses opened in Tuskegee, Alabama, in 1941. It graduated 31 students before it closed in 1946.^[43] Funding came from the Rosenwald Foundation and the Children's Bureau through the Macon County, Alabama Health Department. In 1941, Rosenwald was directed by Edwin Embree who had a long-standing interest in midwifery. Embree hired Mary Beard in her position as a staff member of the Rockefeller Foundation to study the relationship between midwifery care and improved maternal child health. After moving to Rosenwald, he used his position to expand the profession in the South.

Hazel Corbin and MCA were also central to this expansion of nurse-midwifery and development of the Tuskegee program. In preparation for opening the educational program, the Rosenwald Foundation sent four African American nurses to MCA for education in midwifery.^{[44,45,46,47]} They returned to Tuskegee to run the nurse-midwifery clinical service beginning in 1939.^[48] Once the school was open, they participated in the clinical education of student nurse-midwives. Both Rosenwald Foundation ^[49] and the Macon County Department of Health ^[50] requested that MCA identify a white nurse-midwife to direct the Tuskegee program. Although the record shows that Alabama officials were insistent that a white nurse-midwife lead the project initially, they were open to the possibility of African American leadership once the school was established. Margaret Thomas, CNM, an MCA graduate, directed the school between September of 1941 and March 1942. At that time, she was replaced by F. Carrington Owen, CNM, an African American nurse-midwife and MCA graduate.^[51]

Owen's tenure was short, however, and she resigned in June 1943,^[51] because of southern segregationist ideology and policy. She received a salary $800 lower than Thomas' for the same position, because she was African American. MCA's director, Hazel Corbin was displeased and wrote to B. F. Austin, acting State Health Officer in Alabama's Department of Public Health, requesting an increase in the $2,400 annual salary offered to Owen who "has more academic education than Miss Thomas."^[52] Corbin's request was refused. In Alabama, color rather than qualifications determined earning potential. Owen chose to relocate to a northern city in June 1943, and Margaret Thomas returned to Tuskegee to run the program until August 1945. Thomas was replaced by the third and last director of Tuskegee, Claudia Durham, CNM, a Tuskegee graduate, who supervised the program until it closed in 1946.^[51]

Perhaps the most famous graduate of the Tuskegee program was Maude Callen, CNM, whose midwifery practice was captured by the camera of Eugene Smith for the readers of Life in December 1951. Callen is pictured educating apprentice-trained African American midwives, providing care in a prenatal clinic, providing labor support, delivering a healthy baby, handing a newborn to his smiling mother, and providing routine public health nursing services to some of the 10,000 residents in rural Berkeley County, South Carolina. Her monthly salary of $225 was often not enough to cover annual dues for ACNM membership.^[53,54] Other examples of nurse-midwives employed by state health departments to provide comprehensive maternity services can be found in Georgia and Maryland.^[55]

During the late 1940s, the number of traditional midwives in Georgia was dwindling, and there were not enough providers to care for poor women in several rural counties. By the decade's end, nurse-midwives became involved in several demonstration maternity services that allowed them to provide prenatal, intrapartum, and postpartum care in both freestanding "maternity shelters" and in community hospitals.

In 1942, the first demonstration service opened in Georgia's Rabun County, which had no practicing midwives to care for poor African American women. Josephine Brewer, CNM, a nurse-midwife who had been supervising African American midwives, worked with a community group to establish a "maternity shelter" or community birthing center. Most of the time physicians managed deliveries, but when they did not arrive in time, Ms. Brewer stepped in and delivered the baby. In 1947, the second and third demonstration services were established. A nurse-midwife home delivery service was established in Thomas County, and a hospital based nurse-midwifery delivery service began in Walton County. The home delivery service did not attract many women, but the hospital service was successful because nurse-midwives attracted patients who previously would have used traditional midwives, thus increasing the number of hospital births. In 1951, the fourth demonstration, a "maternity shelter" opened in Lamar County staffed by three nurse- midwives who offered full scope maternity care.^{[56,57,58,59]}

After evaluation, the state health department found that the projects successfully demonstrated that "nurse-midwives could contribute something valuable to obstetric practice" by replacing the local midwives with well trained nurse-midwives.^[56] Ernest Thompson, MD, Walton County Health Commissioner, wrote, "the nurse-midwife program... has proved to be a satisfactory solution to the problem of maternal care for the very low income group."^[58] By the mid-1950's, the programs had been in existence for six to nine years and were well integrated into county health department programs. The seven nurse-midwives involved were each delivering about 66 babies annually. After introduction of the nurse-midwife programs, the project counties experienced the following: a drop in maternal mortality compared to the rest of the state; an increase in the average number of prenatal visits over state averages; earlier registration for care; and high physician acceptance of the nurse-midwives' contribution. Unfortunately, these projects were discontinued in the early 1960s due lack of funding.^{[56,57,58,59]}

Scarcity of physicians and high maternal and infant mortality were not confined to African Americans in the deep South during the 1940s. At the beginning of the decade, both problems were present in Santa Fe, New Mexico. The situation in New Mexico became critical after the United States entered World War II and physicians were drafted for the war effort. Both the Catholic Archbishop for the region and the regional director for the Children's Bureau concurred that introduction of nurse-midwives might provide a solution that would be acceptable to families in need of services. A request from the Archbishop to Mother Dengel, Superior-General of the Medical Mission Sisters, put in motion organizational changes that permitted the sisters, whose work abroad was restricted by war, to serve in the United States.^[31,41,60]

In 1942, Sisters M. Theophane Shoemaker, CNM (hereafter referred to as Sister M. Theophane), and Helen Herb, CNM, enrolled in MCA's midwifery school. In 1943, they began providing prenatal care at the Catholic Maternity Clinic in Santa Fe, with financing from the Children's Bureau, and began assisting the clinic physician when she attended a private patient's labor and birth at home. In less than a year, Catholic Maternity Institute (CMI) opened as a clinical nurse-midwifery practice and educational program. Most women who obtained care at CMI gave birth at home. When they lived too far away from CMI for nurse-midwives to easily and safely reach them for labor and birth at home, families were invited to come into Santa Fe and birth at La Casita, a small homelike birth center at CMI.^[31,40,60] Although the maternity shelters in Georgia and La Casita in Santa Fe were designed to care for poor women who had no other alternatives, they became models for the free-standing birth centers of the 1970s, 1980s, and 1990s, which were designed to attract middle-class women to nurse-midwifery care.

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.