League of Women Voters

A look at midwifery then and now


Happy Women’s History Month! We turn to one of the oldest professions for women, relevant in a county where maternal healthcare options have been decreasing.

“Midwifery is an ancient practice, passed down through the hands of women through generations,” write researchers Barbara Ehenreich and Deidre Stephens, in “Nurses, Midwives and Witches.”

“Midwives are the guardians of a natural process, honoring the sacred bond between mother and child ... There is no greater privilege than bearing witness to the miracle of life.”

Women attended women’s bodies for the greater part of human history. Like the 18th century midwife from Maine, Martha Ballard, they learned to treat other ailments and earned the trust of their communities. In Ballard’s journal, we can see how residents of Hallowell, Maine called for Ballard both for births and illness. She wrote on Sept. 23, 1786: “I was called early this morning to see Lidia Savage who was very ill. Gave her some urine and honey and some licourice and put a plaster to her stomach. Went up afternoon. Find her relieved.”

Ballard’s medicinal wisdom may strike us as suspect homeopathy, but the U.S. had almost no medical colleges or trained doctors. Often these treatments had been tested, tried and transmitted between healers and midwives, Ehrenreich and Stephens write. Meanwhile, the emergent medical field in Europe included physicians who treated only the wealthy, frequently refused to touch patients, lacked the tested field expertise and wisdom of lay healers, and saw surgery as barbarism. Professionalizing medicine in Europe meant receiving the approval of church leadership, which tended to mix up affliction and healing with sin and grace. Lay healers and midwives had a body of tested treatments and practices and were absolutely necessary in the absence of doctors for most households.

Ballard herself birthed nine children and attended nearly a 1000 births. Some accounts say only five infants died under her care. Her rate of success of infant mortality was so low that modern medicine in the U.S. would not achieve anything comparable until the 1940s.

But as modern medicine took root, Ehrenreich and Stephens’ research shows that many midwives and lay healers faced accusations of “witchcraft” if they practiced too far out of the borders of religious approval or ran afoul of professionalized medicine. In the newly formed United States, midwives faced a double bind. They couldn’t attend the few medical schools and quickly faced legal prosecution for practicing care without an education.

Modern midwifery in Indiana has faced all manner of double binds. Until 2013, only certified nurse midwives could practice legally, and they had to deliver in hospitals or licensed birth centers. Women seeking home births had to turn to midwives working outside of the borders of the law.

Internationally, midwives have exceptional birth rates. While there are decades of studies, a 2020 comprehensive look at 16 studies in the Lancet looked at outcomes: “Among low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes,” like c-sections, operative vaginal births, infections, oxytocin augmentation, episiotomy, or significant tearing.

Midwives practice what is called “physiologic” birth assistance, teaching women during prenatal visits how to interpret their bodies’ signals ­— testing blood pressure, blood sugar, hormone levels, and interpreting weight gain, measurements and fetal signals like heart rate — to understand their pregnancies. Both certified nurse midwives and direct entry midwives screen out high risk pregnancies.

“Midwifery is a partnership between midwife and family,” said Samantha Brinkerhoff, a direct-entry midwife in Vigo County. Obviously that partnership focuses on the pregnant woman, but involves the whole family, she said. Midwives lend their expertise, but put the woman and her family in charge. “Women are encouraged to be active participants in making choices about their care. We let them know they are free to choose other options, which is very different from the hierarchical medical model where women are being told what to do.”

In the practice with which Brinkerhoff works, they spend more time with families, not just educating them, but getting to know the women and families — their preferences, fears, concerns — so they can address those ahead of time. They build trust during prenatal care, which comes in handy during the birth. If a midwife says during labor that there is a problem, and they need to transfer to a hospital, women and families trust the call. Under Indiana licensure law, midwives must ensure women have written an emergency plan for such situations.

In physiologic birthing, midwives “are like life guards on the sidelines. Home birth provides women the privacy of their home, the freedom to move around, eat and drink, while being supported through the natural process of progressive labor, so it leads to better outcomes.” Medically managed births tend to be more micro-managed, keeping women in a room or bed, limiting food and drink, using pitocin, which snowballs into further interventions.

Brinkerhoff began practicing as a midwife after Indiana passed a law in 2013, legalizing home births and direct entry midwives - a midwife credentialed without first becoming a nurse. Though certified nurse midwives still practice in birthing centers and hospitals, it’s usually in urban areas because larger hospitals offer labor and delivery. They practice there, though they are not always well-integrated into the system. In recent years, a number of certified nurse-midwife services have been eliminated in Lafayette and Indianapolis.

Unlike other nations, midwifery in the U.S. lacks the clout and integration in the medical system as a whole. As Ehrenreich and Stephens found in their research, the professionalization of medicine and exclusion of women from medical schools created an impression that midwifery is “substandard care.” Brinkerhoff noted this as well. “Some families want “the expert” surgeon or the best, the most highly qualified, and that midwives are not as qualified or competent to provide care in emergencies,” said Brinkerhoff. “We midwives are comfortable in acknowledging that we are not surgeons, and we will screen during pregnancy and monitor during labor and delivery.”

The signal has been that every birth needs an expert at any second. In reality, most births proceed normally and midwives competently manage any warning signs early enough to transfer women to a hospital in time, says Brinkerhoff.

In the U.S., home and midwife assisted births are gaining popularity. The problem is accessibility. Ideally, an increase in midwife-assisted births would help with the maternal and infant healthcare deserts in rural counties like ours. Of course, rural hospitals and counties would need supportive physicians trained for emergencies who are willing to relinquish low-risk pregnancy care. Midwives, like medical professionals, are facing steep increases in liability insurance. Because they spend more time with their patients and must be on call for each birth, midwives don’t increase volume of patients to offset rising insurance costs. Women’s insurance doesn’t cover midwives either, making it an option only for those who can pay out of pocket.

“In the past midwives served women who couldn’t afford doctors,” said Brinkerhoff, but the practice has always been to put women’s needs first. It’s a holistic approach to birthing, one that doesn’t see it as a medical problem, but the natural process.

For information, visit the website www.lwvmontcoin.org or the League of Women Voters of Montgomery County, IN Facebook page.