The professionalization of obstetrics in the early 20th century led to the marginalization and, in some cases, the eradication of traditional "granny midwives," particularly impacting African American communities in the South. These midwives, often the primary healthcare providers in their communities, were systematically displaced by emerging medical regulations and licensure requirements that favored formally trained physicians.
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The push for modernization introduced expensive credentialing processes, creating barriers for traditional midwives who lacked formal education but possessed extensive practical experience. This shift not only sidelined seasoned practitioners but also replaced them with younger professionals who may have lacked the cultural competence and community trust that "granny midwives" had established over generations.
In Pennsylvania, the legal landscape for midwifery is complex. The state's Midwife Regulation Law prohibits the practice of midwifery without a license. However, Pennsylvania does not provide a licensure pathway for non-nurse midwives, effectively rendering the practice of lay midwifery illegal.
Despite this, non-nurse midwives continue to attend home births, operating in a legal gray area.
Advocates argue that preserving the practice of lay midwifery is essential for providing accessible and culturally sensitive care, especially in underserved communities. They contend that the current legal framework should be re-evaluated to support the inclusion of traditional midwives, recognizing their valuable contributions to maternal and infant health.
The intersection of modern obstetrics and traditional midwifery has led to the marginalization of "granny midwives" through stringent licensure requirements and the prioritization of formal medical credentials. In Pennsylvania, the lack of a licensure pathway for non-nurse midwives presents legal challenges that merit reconsideration to protect and integrate lay midwives into the healthcare system.
The commercialization of midwifery has fundamentally altered its craft, shifting it from a community-based, holistic practice to a more clinical and transactional profession. Historically, midwifery was deeply rooted in tradition, community trust, and lived experience. The midwife was often a respected elder with years of accumulated knowledge passed down generationally. This approach centered on the natural processes of childbirth, with a focus on the physical, emotional, and spiritual well-being of the mother and baby.
Impact of Commercialization
Shift Toward Medicalization:
Modern midwives are increasingly trained within frameworks that prioritize interventions, often mimicking the practices of obstetricians (OBs).
Traditional tools, such as herbs and massage, have been replaced with technology-heavy practices.
The result is a loss of the essence of midwifery as a gentle, patient-centered craft, as it becomes more aligned with the efficiency-driven model of hospital obstetrics.
Loss of Personal Connection:
Where midwives once served communities over decades, building trust and deep cultural competence, the emphasis on credentials and licensing has created a transient workforce.
The reliance on formal training often devalues lived experience and the importance of cultural traditions in caregiving.
Exclusion of Traditional Midwives:
The commercialization process systematically excludes older or lay midwives who cannot afford the expensive credentialing process or conform to standardized medicalized practices.
Challenges of Young Midwives in Traditional Roles
Lack of Life Experience:
Midwifery is more than a technical skill—it requires intuition, maturity, and emotional resilience developed over time.
Young, newly credentialed midwives may excel in clinical knowledge but lack the seasoned judgment and empathy needed for traditional midwifery's nuanced and intimate role.
Ego and Misalignment with Tradition:
Some younger midwives, influenced by competitive training environments, may prioritize their own professional advancement over the relational aspects of care.
This mindset contrasts sharply with the humility and patience central to traditional midwifery.
Adopting Obstetric Practices:
The pressure to align with obstetrics can lead young midwives to rely on interventions such as inducing labor, vaginal exams, and frequent attempts at controlling a labor- diluting the naturalistic essence of midwifery.
Transformation of Traditional Practices
From Holistic to Procedural:
Practices such as honoring the laboring mother's natural rhythms, using natural pain management techniques, and engaging the family unit have been sidelined.
In some cases, midwives are indistinguishable from OBs in their approach to time management and delivery goals.
Institutional Constraints:
Midwives operating within hospitals are often subject to policies that limit their autonomy, forcing them to adhere to institutional protocols rather than individualized care.
Why This Matters
The commercialization and professionalization of midwifery, while bringing certain advancements in safety and accessibility, risk eroding the heart of the practice. The shift to an OB-like model and the focus on credentialing exclude traditional wisdom and lead to a loss of diversity in care approaches. Midwifery needs experienced, intuitive practitioners who see birth as a holistic event rather than a clinical task. Re-centering the craft around its traditional roots, while integrating safe modern practices, is essential for preserving its integrity.
The professionalization and licensure requirements for midwifery have led to the criminalization or marginalization of traditional and lay midwives in many parts of the United States and globally. Here are examples illustrating how licensure and regulatory frameworks have negatively impacted midwifery, particularly traditional and lay practices:
United States Examples
Hawaii:
In Hawaii, a 2019 law mandated that all midwives must be licensed through the Certified Professional Midwife (CPM) credential, effectively criminalizing lay midwives.
The law excluded cultural practitioners and traditional midwives who served Native Hawaiian and rural communities, threatening to erase culturally significant birth practices.
New York:
In New York, practicing midwifery without a license is considered a felony, effectively shutting out traditional and lay midwives.
The state requires midwives to become Certified Nurse Midwives (CNMs), which involves expensive and time-intensive schooling, inaccessible to many traditional practitioners.
This has disproportionately affected communities that relied on midwives for culturally sensitive care.
New Jersey:
In New Jersey, state laws heavily regulate midwifery, requiring CNM credentials and physician oversight, which limits the ability of independent midwives to practice.
Traditional midwives who have long served immigrant and marginalized communities find themselves unable to practice legally.
Florida:
Florida requires midwives to be licensed under strict regulations, leaving lay midwives without a pathway to legality.
Practicing midwifery without a license is a felony in the state, making it risky for traditional practitioners to serve their communities.
Global Examples
Sweden:
Sweden's midwifery model, while considered one of the best in terms of outcomes, excludes traditional midwives entirely.
The state licenses only highly trained midwives with medical degrees, eradicating home-based, traditional practices.
South Africa:
In South Africa, increasing medicalization has marginalized traditional birth attendants (TBAs), who are now heavily restricted by law.
While TBAs were once integral to rural care, they are now illegal in many areas unless operating under strict medical supervision.
Australia:
Similar to the U.S., Australia requires midwives to register through a national board, and those practicing without credentials face fines or legal action.
This has significantly reduced the number of midwives offering home births and traditional care options.
Impact of Licensure Laws
Licensure laws, while aimed at standardizing care and ensuring safety, often fail to account for:
The cultural and historical significance of traditional midwifery practices.
The economic and educational barriers that make credentialing inaccessible to many traditional practitioners.
The needs of communities that prefer or rely on midwifery due to cultural, geographical, or personal reasons.
By criminalizing midwifery without addressing these factors, states and countries risk erasing centuries of community-based care.
What Can Be Done
Pennsylvania as a Model: Pennsylvania's legal gray area for lay midwifery, while imperfect, stands out as an example worth preserving. This model provides a framework for other states to protect lay midwifery and its cultural significance. Lay midwives now have access to an NPI number, the ability to request labs and ultrasounds, & complete birth certificates and social security paperwork, & perform newborn screenings.
Advocacy: Communities, particularly those in rural or underserved areas, must advocate for inclusive licensure pathways that respect traditional and lay midwives.
Global Perspectives: Learning from countries with more integrative systems, such as the Netherlands, where midwives work in partnership with hospitals while preserving their autonomy, could provide solutions.
Midwifery is not just a medical profession; it is a cultural and community-centered craft that requires protection from the erasure caused by overmedicalization and strict licensure laws.
Books
"In the Way of Our Grandmothers: A Cultural View of Twentieth-Century Midwifery in Florida" by Michelle B. Lacy
This book details the cultural and historical significance of midwifery in African American communities in Florida, including the impacts of medicalization and licensure on traditional "granny midwives."
"Listening to Mothers: Midwives on Childbirth" by Lisa Gould Rubin
Provides first-hand accounts of midwives navigating the tension between traditional practices and modern medical frameworks.
"Birth as an American Rite of Passage" by Robbie E. Davis-Floyd
Examines the cultural and medical paradigms shaping childbirth practices in the U.S., with a critical view of obstetric dominance.
"Granny Midwives and Black Women Writers: Double-Dutched Readings" by Valerie Lee
Explores the roles of "granny midwives" in African American culture and literature, with a focus on their erasure through medicalization.
"Midwives, Society, and Childbirth: Debates and Controversies in the Modern Period" edited by Hilary Marland and Anne Marie Rafferty
A global perspective on how midwifery has been impacted by professionalization and regulation.
"Reclaiming Birth: A History of Midwifery in the United States" by Margot Edwards and Mary Waldorf
Focuses on the history of midwifery in the U.S. and its decline under medical and legal pressures.
"A Midwife's Tale: The Life of Martha Ballard, Based on Her Diary, 1785–1812" by Laurel Thatcher Ulrich
Chronicles the life of an 18th-century midwife, offering insights into the traditional practices that preceded modern regulation.
"The Archetype of the Birthgiver: Midwifery and Feminism in Modern America" by Judith Pence Rooks
Discusses the feminist movement's intersection with midwifery and the challenges posed by modern credentialing.
Articles and Studies
Temple Law Review: "Solving the Modern Midwife Problem: The Case for Non-Nurse Midwifery Legislation in Pennsylvania"
Analyzes Pennsylvania’s legal framework and the need for inclusive licensure for lay midwives.
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"Licensure of Traditional Midwives: Impacts on Culturally Competent Care" by Wanda Irving
Explores how licensure disproportionately affects marginalized communities reliant on traditional midwives.
"The Decline of the Granny Midwife in the South" by Charles G. Roland
Historical account of how regulatory frameworks displaced African American midwives in the Southern U.S.
"The Impact of Midwifery Licensing on Maternal Health Outcomes" by Brianna Dahlberg
Examines the legal changes surrounding midwifery and their implications for community-based care.
Citations
Lacy, Michelle B. In the Way of Our Grandmothers: A Cultural View of Twentieth-Century Midwifery in Florida. University Press of Florida, 2000.
Davis-Floyd, Robbie E. Birth as an American Rite of Passage. University of California Press, 1992.
Lee, Valerie. Granny Midwives and Black Women Writers: Double-Dutched Readings. Routledge, 1996.
Ulrich, Laurel Thatcher. A Midwife's Tale: The Life of Martha Ballard, Based on Her Diary, 1785–1812. Vintage Books, 1991.
Edwards, Margot, and Waldorf, Mary. Reclaiming Birth: A History of Midwifery in the United States. University of Michigan Press, 1984.