The following is a Woman of Courage profile produced by the St. Lawrence County, NY Branch of the American Association of University Women.

The Birth of Nurse-Midwifery in America

When Laura Ettinger, Ph.D, from Clarkson University presented "The Birth of Nurse-Midwifery in America" at the February 2000 Women's History Round Table, the participants gained some understanding of the continuing mix of attitudes toward the services that nurse-midwives are trained to provide.

On the one hand, we need nurse-midwives. As Ettinger puts it, "The uneven distribution of maternal and infant health services points to the continuing need for nurse-midwives in the United States. Despite spending more of its gross national product on health care than any other country in the world, the United States ranks 22nd in infant mortality rates, behind most industrialized countries.

"The two statistics are related: middle and upper-class Americans can buy access to the best health care in the world, while uninsured and underinsured Americans receive few of the benefits of this care, and thus, the infant mortality rate reflects lack of access to primary, preventive and specialist health care services by lower-income patients."

A similar statement could have been made back in the 1920s when nurse-midwives, who are qualified nurses with special training in obstetrics, began to replace traditional midwives.

One physician argued that "the nurse-midwife will prove to be the most sympathetic, the most economical, and the most efficient agent in the case of normal confinements."

On the other hand, there continues to be resistance to including the profession of nurse-midwifery in the health care system. "Some physicians worked against nurse-midwives by denying them hospital privileges, and by opposing state laws which recognized nurse-midwives, permitted third party payments, and/or allowed prescriptive authority. Other physicians supported nurse-midwives, providing consultation, collaboration and referral."

Ettinger cited several internal and external problems that continue to face nurse-midwifery today. Some nurse-midwives do not think nursing school is necessary for certification in midwifery believing that the emphasis on disease and on men's as well as women's health is not helpful for midwives.

Even in states with laws that grant nurse-midwives a fair amount of autonomy in birth management, the guidelines and policies of some hospitals tightly restrict nurse-midwives and show the physicians and hospital administrators skepticism about their work. And many Americans continue to misunderstand who nurse-midwives are and what they do.

Today, nurse-midwives are well-trained professionals who provide obstetrical, gynecological and primary health care to women throughout the United States. They are employed in many settings: hospitals, office practices and public health departments. Nurse-midwives work within a health care system that provides for medical consultation, collaboration and referral as appropriate. The practice of nurse-midwifery in America, Ettinger said, started in 1925 in the Appalachian mountains in Kentucky, a region with very few physicians and one of the highest maternal and infant mortality rates in the United States.

Mary Breckenridge, a nurse from a distinguished southern family, started Frontier Nursing Service as a nurse-midwifery demonstration site. First by horseback and later by jeep, Frontier Nursing Service nurse-midwives traveled through the mountains to offer prenatal, labor and deliver and postnatal services for women, as well as public health programs for men, women and children.

They held weekly clinics for prenatal examinations, inoculations, and advice on child hygiene, and sanitation. They dramatically improved their patients health. After the founding of Frontier Nursing Service, nurse-midwifery programs gradually developed in rural and urban places around the country.

In 1989, Frontier Nursing Service developed a distance learning program, Community-based Nurse-midwifery Education Program (CNEP), thus continuing their tradition of practice outside the hospital in rural areas.

By the mid-1990s, CNEP had students in every state. CNEP enables nurses in small towns and rural areas to become nurse-midwives By 1996, there were 50 nurse-midwifery educational programs in America, some based in hospitals and medical centers. Although traditionally nurse-midwives had worked with the poor and medically underserved population, in the early 1970s they began going into private practice, working with physicians and serving middle- and upper-class women.

There was a shortage of obstetricians at the time, and women were demanding an alternative approach to birth. Partly because of the women's movement in the 1960s and 1970s, many women became more vocal in their criticism of routinized hospital births. They did not view pregnancy as a disease or an illness, and wanted to actively participate in the birth process. They wanted their husbands with them as they delivered their child.

They learned about natural childbirth and breast-feeding. They found that a nurse-midwife provided this kind of support and guidance. The nurse-midwife had the back-up of a physician in the event of some complication with the pregnancy or birth.

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