Obstetrics and gynecology in America: a history.

The discussion places the current occupation of certified nurse-midwives (CNM) within the historical context of the decline of lay midwifery in the US and documents the development of nurse-midwifery as well as current problems facing this profession. In colonial America the post of the midwife was one of the most important in the community. Women had virtual monopoly over the practice due to the fact it was considered beneath the dignity of male physicians to act as obstetricians. Some historians identify the years before 1750 as the "age of the midwife." Doctors were few and midwives delivered all of the babies. By the 1780s the shift away from midwives toward doctors among the more affluent segments of the population in the cities was noticeable. The most serious problem associated with the increased use of physicians over midwives was an increase in mortality both maternal and infant. Physicians were more likely than midwives to employ instruments in delivery and prior to the discovery of the need for antiseptic conditions interference by physicians with instruments was extremely hazardous and frequently led to the death of the mother from puerperal fever (blood poisoning). Despite the dangers of death from puerperal infection the use of midwives declined steadily. As the demand for midwives in the US declined in the 1920s and home deliveries were replaced by hospital births throughout most of the country by 1930 1 area made a concerted effort to initiate a midwifery program. In Hyden Kentucky Mary Breckenridge along with several British-trained nurse-midwives began the Frontier Nursing Service in 1925. The efforts of Breckenridge were particularly unique because the practitioners were not only midwives but trained and certified public health nurses. Thus a new concept in maternity care was established combining the ancient art of midwifery with the modern scientific training provided for nurses. In 1971 the American Nurses Association of the American College of Obstetricians and Gynecologists the ACNM and the American College of Obstetricians and Gynecologists collaborated on a joint statement approving the management of normal labor and delivery by CNMs under supervision of a qualified obstetrician. The statement was tantamount to professional recognition of CNMs as legitimate maternity practitioners and thus fostered their acceptance into modern obstetrical practice. At this time there are about 2800 CNMs practicing in the US. While the ACNM has undertaken many attempts to increase acceptance of CNMs by the public and the medical profession the acknowledgement of the professional competence of CNMs has been slow and cautious.