Just a note for historical reference. The transition to hospitals was not necessarily the reason for improved maternal and infant mortality rates in the mid 1900’s. The increasing use of antibiotics helped to treat infection (particularly “child-bed fever”) and played a significant role in improving maternal/child health. Also note that at this same time the Frontier Midwifery Service headquartered in Hyden, Kentucky had excellent outcomes in rather primitive conditions.
Thank you for your comment, Bonita. This history is so interesting, and you’re right that the improvements in neonatal and maternal mortality were multifactorial. During the development of the field of obstetrics in the early 1900’s, its leaders openly admitted that women were at least as safe birthing with experienced midwives as with physicians, and part of the “midwife problem” they discussed was their own acknowledgement that medical students needed better training. (See the 1912 JAMA article by J. Whitridge Williams, for example – https://jamanetwork.com/journals/jama/article-abstract/450091)
The push towards hospitals likely made things worse before they made things better, because of increased infections, risky pain medications, and overuse of instrumental deliveries. The CDC link in the article mentions many other factors contributing to improving outcomes over the 20th century, including better nutrition, longer spacing between children (i.e. availability of contraception and safe abortion), antibiotics, creation of Medicaid and other federal aid programs, and advances in neonatology like use of pulmonary surfactant, in addition to improving obstetric care with better education, training, and advances in research.
And yes, nurse midwives were quietly working in Appalachia and in New York City as early as the 1920s, with excellent outcomes. La Casita in Santa Fe is thought to be the first freestanding birth center in the United States, started by Catholic missionary nurse-midwives in the 1940s. However, my understanding is that nurse midwifery was a small field focused on caring for under-served women (and not competing with obstetricians) until around the 1970s.
I am a CNM in a physician-owned free standing birth center. It really offers the best of everything! Midwives who believe in the normalcy of pregnancy and birth, but who are able to seamlessly provide care when things deviate from normal because of our fantastic collaborative practice MDs and our hospital privileges.
Please give Dr. Christina Sebestyen of Austin, Texas praise for being a proponent of safe out-of-Hospital births!
Nice to see some doctors in the USA are finally catching on to what midwives have been doing for ages in other places. Our two oldest were born in a birthing center run by midwives in Melbourne Australia in the 2000’s. So much better than the hospital birth for our third in a London Hospital 2012, which wasn’t terrible but just not nearly as ‘normal’. Fortunately we didn’t stay long…
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