A history of midwifery
 
Although the rise of midwifery as a respected profession varies from country to country –
most histories go far back, well before the rise of modern obstetrics. What is often forgotten
by modern health systems and policy analysis is that, in most instances, midwifery has not
grown out of, or been a specialist branch of nursing, rather has its origins in social welfare
and public health. In the UK for example, historical writings show it was social reformers and
suffragettes who, with some far-looking medical practitioners, lobbied hard for the first
Midwifery Act in 1902, their previous four attempts in the later 1800’s having been thwarted
by traditional, often pious, medical physicians. In the USA the origins of midwifery, like
elsewhere can be found in the poorest communities, such as the “wise women” in African
slave communities, but also the more famous Frontier Nursing Services who, although were
nurses first, did not work in hospitals or institutions, rather they went out to deliver poor
women on horseback. In ancient Egypt midwives were found in temples and midwifery was
considered only suitable for god-fearing women, whilst in the middle-ages in Europe many
midwives faced fear, public ridicule and punishment as witches from formal church
institutions. In more modern times, in other parts of the world, midwifery is also strongly
associated with religious communities, or care for and service to poor women. Thailand’s
history of midwifery for example can be traced back to the late 1800, with a school for
midwives, the first school or either nursing or midwifery, being open by the Queen, to
provide care for poor women. In Chile houses for midwifery training have a long and
distinguished history, and although Chilean midwives and growing numbers of midwives in
other Latin American countries are used by pregnant women from all socio-economic
groups, historically they too gave service initially to the poorest.

Working with and serving women in the community is to be found in almost all countries,
even those that now have more than 90% of births in a facilities – like Sweden. The early
midwives were strong and had a deeply held conviction for assisting women in what was
seen as a normal part of life, but one which could on occasions rob a family of their most
treasured possession –mothers. Their caring for women and families meant that in many
cases midwives were well respected in society; many having a special place in history, as
can sometimes be seen in some places when reading inscriptions on headstones in ancient
commentaries /burial grounds for example.

Midwifery, as a profession and those who practice midwifery, are less beholden to the
teachings and tenants of Florence Nightingale and nursing dogma, than some profess.
Although Florence Nightingale did open a school of midwifery, as her own diary shows, she
soon closed it declaring that “these midwives were un-trainable”!. These midwives she refers
to, like the early recruits into midwifery in Africa, were not young women from gentle families,
but rather many were married women who themselves had given birth and knew the need
for quality care to save the lives of not just the mother, but also the newborn. In many
countries in Africa the early history of midwifery owes much to the early missionaries and not
armed warfare - which required building a nursing cadre to care for wounded and dying
soldiers. Many of the early programmes for midwifery were less formal than those for
nursing and often seen as being at a lower academic level. Although in many African
countries midwifery is often incorporated into nursing curricular and is not provided as a
separate programme, some, such as Burundi and Rwanda, did develop specialist midwifery
programmes. In the late 1960, concern for the high level of maternal mortality in Africa a
number of others countries, such as Zambia open professional midwifery schools for
registration as a midwife. These in turn were developed into a diploma level programme and
other countries have in recent years followed this route. These programmes are mainly

Prepared as a background document for The State of the World’s Midwifery 2011 - launched June 2011
Disclaimer: While all efforts have been made to verify the information in this document, responsibility for the contents and presentation rest with the author(s).
The views and opinions expressed in the document do not necessarily correspond with those of the State of the World’s Midwifery 2011 Editorial Committee.
  

focused of midwifery care in institutions, although many did keep a focus on first level care,
close to where women live.

Countries such as Yemen and Sudan, where the majority of the births still take place in the
home or community, have for many decades been building their professional midwifery
workforce, albeit with limited success to date on community services. In Sudan, since 1926
they have done this by focussing on trying to reach out to women in the community,
especially poor communities, to encourage women from these communities to train as
midwives and then return to their communities to work. Experience from other countries
shows that once the community finds these health workers (midwives) acceptable, they are
then more willing to seek out their services and to be referred to and in time seek care from
maternity facilities that can offer the full range of essential obstetric (and midwifery) care.
Initially however, communities, especially rural communities, and more so socio-
economically poor and marginalized communities, will have little contact with the formal
health sector and therefore have no trust in the providers or the services they provide
whatever their profession. As trust between women, their families and communities and the
professionally trained midwives grew, so did the use of and demand for midwives.

Experience from other countries such as Malaysia and Sri Lanka show that with time, such
trust and confidence in the new cadre can be achieved. The focus was on going out to
communities and making links and partnerships with the traditional birth attendants (both the
trained and non trained TBAs) as well as partnerships with physicians. Malaysia initially
followed a British model and developed licensing and regulation early in the development of
their health system. Midwifery in Malaysia is now a highly specialised training following after
public health nursing and, midwives are to be found at all levels of the health services,
including in rural midwifery-led facilities. Sri Lanka however, despite initial similarities with
Malaysia, has not developed their community-based public health midwife. Although some
public health midwives have moved from community practice into hospitals where the
majority of women now give birth, they are not treated with high regard, but rather must work
as auxiliary staff under the supervision of a Registered Nurse who has 6 months additional
training in midwifery after nursing programme. The difference between the Sri Lanka and
Malaysia models of midwifery and the Indonesia model, was that the village midwives in
Indonesia were not known in the community and did not come from the community they
were located in, thus initially there was resistance to these young (and it must be admitted,
inexperienced) health providers. With time however and as these young women have
matured and in many cases had children of their own in the communities they work in, the
community has begun to accepted them and are now more readily seeking care from these
midwives. It should also be acknowledged that the government of Indonesia has also
worked extensively over recent years to increase the capacities and skills of these
community midwives (bidan di desa) through in-service training efforts. A recent evaluation
of these efforts show that the community midwife is now a well respected figure in many
communities, and is sought out for skilled care as well as family planning matters and many
other issues.i In contrast, the models in Yemen and Sudan have tried from the start to
ensure that the community midwives come from, or have links with the community they
serve, even if they have to first move away from their community for pre-service training.

It is only in more recent times, across many countries of the world, that for expedience,
managers and administrators have grouped midwives and nurses under one professional
grouping, and often placing at the head a nurse, rather than a midwife. This subsuming
midwifery into nursing has done much to account for both the disappearance of midwifery in
some countries, but also poor quality of care; as in such cases midwives are no longer able
to become expert leaders, academics and researchers to advance the art and science of

Prepared as a background document for The State of the World’s Midwifery 2011 - launched June 2011
Disclaimer: While all efforts have been made to verify the information in this document, responsibility for the contents and presentation rest with the author(s).
The views and opinions expressed in the document do not necessarily correspond with those of the State of the World’s Midwifery 2011 Editorial Committee.
  

midwifery. It is only in those countries that have been able to hold fast to the identity and
autonomy of midwifery, or the newer countries like New Zealand and Canada which have
fought hard to create the space and definition of autonomous midwifery practice, that can
boast of a strong professional midwife cadre. It is also noticeable that in those countries with
a strong identifiable cadre of midwives, where numbers of midwives can be counted and
where midwifery is regulated, the MMR is low, or lower than other countries with
comparative economic growth and development and the status of women is usually higher
than others.

On one final note, every midwife who practices midwifery-led care knows, the most
important thing to the pregnant women, even sometimes sadly above her own life, is the life
and survival of her child. Thus the misnomer that midwives only care for women and not
newborns, is the result of medicalization of childbirth; for it is only in institutions that mothers
will permit to ever get separated from their newborns. Thus, the philosophy or midwifery–and
the real tenants of midwifery practice can be found in empowerment of women, helping
pregnant women progress through their pregnancies, then give birth –to a new being, a new
family member and after to adjust to and care for this new family member. Because the
bringing of new life is as much a social and spiritual activity as it is physical, midwives must
have at the centre of their practice the elements of social welfare – helping women not only
to prepare mentally and adjust, but physical practical preparations, make savings for the
birth for the additional food, clothing and other items. It is the centering on an empowerment
modality and, compliance with spiritual norms, as seen by the account in the Bible in Old
Testament, whereby the ancient midwives fear the wrath of their god more than the ruler of
the day they would not break ethical rules and kill all the new male newborns, that may
explain the special regard in which midwives are held in some countries. It is true however
that midwifery and midwives are not held in high regards in all countries, but often those
places where midwives are not given special regard, are also the countries where women’s
status is low. The narrative of the rise or fall of midwifery, is in most cases interlinked with
women’s lives and status, and too often their poverty and lack of voice.

Prepared by: Della R Sherratt, Midwife Adviser in Laos, UNFPA

                                                                                                                       
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Prepared as a background document for The State of the World’s Midwifery 2011 - launched June 2011
Disclaimer: While all efforts have been made to verify the information in this document, responsibility for the contents and presentation rest with the author(s).
The views and opinions expressed in the document do not necessarily correspond with those of the State of the World’s Midwifery 2011 Editorial Committee.