Book Review

Catching Babies: The professionalization of childbirth, 1870–1920

N Engl J Med 1996; 334:610February 29, 1996

Article

Catching Babies: The professionalization of childbirth, 1870–1920
By Charlotte G. Borst. 254 pp. Cambridge, Mass., Harvard University Press, 1995. $39.95. ISBN: 0-674-10262-2

Throughout the 19th century, midwives delivered a large portion of the babies born in the United States. In the late years of the century, however, a gradual decline in midwife-assisted births began. By 1930, less than 15 percent of births in this country were attended by midwives. Charlotte Borst has carefully detailed this transition, considering the historical setting and the cultural influences.

Borst has focused her study on four Wisconsin counties, chosen for their careful record keeping and for their relatively high initial number of midwives in practice. Luckily, Wisconsin chose to regulate midwives, so the author was able to use state midwifery-license files and the Milwaukee Health Department's register of midwives. These sources, along with census schedules, birth certificates, state physician licenses, and the Milwaukee City Directory, give Borst contemporary information about the background and activity of birth attendants during the years of the study.

In other accounts of the decline of midwifery, historians have focused on the competition between physicians and midwives, suggesting that elitist physicians undermined the credibility of the midwife. Borst presents her own fresh and innovative view of the causes of this gradual change in birth attendants. She proposes that the inability of midwives to develop a truly professional approach to their craft contributed to their decline over these years, when both medicine and nursing began to develop as professions rather than vocations. The cultural, ethnic, and sex-based causes for this are well explored in the book.

Most midwives in the early part of this century and before were middle-aged, married women with children. For the most part, they provided care to local women of similar ethnic background. Few delivered more than an occasional baby. This close relation to the community and the strong family focus did not allow for the professionalization of the craft.

The other health care practitioners developed as professionals by standardizing and improving education and by adding some theoretical science. Credentials based on education and licensing standards allowed physicians and nurses to confirm their special skills and knowledge. In contrast, midwives did not control their education. The schools of midwifery of the time were very dependent on physicians to train and certify their graduates. Midwives did not lay claim to a unique body of knowledge, nor did they participate in the new scientific approach, which was increasingly attractive to middle-class women. Borst presents a convincing argument that this failure to develop as an accepted profession contributed to the decline of midwives in the early part of this century.

Catching Babies is clearly laid out, progressing from an analysis of midwifery to an evaluation of the changing training and focus of physicians. The arguments are easy to follow, well researched, and well substantiated by the depth of material presented. Borst's analysis of the influences of sex, class, and ethnic background is illuminating. The lessons she extracts from the Wisconsin experience can easily be extrapolated to the larger community.

Catching Babies is a thought-provoking book, raising many questions about how we reached our present structure of care. Furthermore, it makes us consider how these same factors may influence the changes we are now struggling with in the fields of obstetrics and gynecology. This book is good reading for anyone interested in medical history, midwifery, or obstetrics, or anyone who simply wants to consider the influences of background, sex, class, and culture on our futures.

Elizabeth J. Buechler, M.D.
Harvard Community Health Plan, Boston, MA 02215