May 5 is the International Day of the Midwife, and the World Health Organization designated 2020 as the Year of the Nurse and the Midwife. With the coronavirus pandemic, midwives have never been more essential as many pregnant women are reconsidering whether they need to be in a hospital to give birth. Midwives trained in home and birth-center delivery, according to one recent New York Times article, are experiencing a “surge in demand.”

But there are not enough midwives to go around, reflecting a systematic bias against midwifery that is deeply rooted in the institutional and legal structure of the health-care industry. Addressing these problems today could not only help pregnant women better navigate the challenge of giving birth during a pandemic, but it could help births in the United States become safer and cheaper.

Over the past three centuries, midwives, once the main source of maternity care, have been degraded as a profession and excluded from the health-care industry.

As early as the 1760s, American physicians, exclusively men, started pursuing obstetrics and gradually replaced female midwives, who had long been central figures in the traditionally all-female birthing room. By the early 20th century, physician-attended births had become the norm in mainstream white society, while black and immigrant midwives continued to serve their communities. In 1900, midwives participated in approximately half of all births; by 1930, that number was down to 15 percent.

This was largely the result of a crusade to elevate obstetrics as a respected medical field in the early 20th century, led by the so-called father of American obstetrics, Joseph DeLee. “The fundamental reason obstetrics is on such a low plane in the opinion of the profession,” DeLee explained to a colleague, “is just because pregnancy and labor are considered normal, and therefore anybody, a medical student, a midwife, or even a neighbor, knows enough to take care of such a function. Once we can convince the profession and the laity that labor has pathologic dignity, we will be able to draw to this specialty the best minds in the profession.”

Framing normal pregnancy and childbirth as a medical problem instead of a physiologic process could effectively eliminate the role of the midwife, whom DeLee characterized as “a drag on the progress of the science and art of obstetrics. Her existence stunts the one and degrades the other.”

Organized medicine also leveraged racism and xenophobia to eliminate all midwives, by focusing on the ones who served vulnerable communities. Thomas Darlington, health commissioner for New York City, stated in 1911: “We know in general that the midwife is commonly employed in this country by the negro and alien populations as well as by many native born of foreign parentage. … Reports prove conclusively that the midwife, with very few exceptions the country over, is dirty, ignorant, and totally unfit to discharge the duties for which she assumes.” This effort simultaneously diminished community-level care and knowledge while boosting the professional fortunes of organized medicine.

Without the inclusion of midwives in the hospital system, support for unmedicated physiological birth disappeared, and generations of women with healthy pregnancies were subjected to medically managed deliveries per the obstetric standards of the day, giving birth under general anesthesia or twilight sleep, with routine episiotomy and forceps deliveries. As the percentage of hospital births increased, so did complaints about these unpleasant, mechanical, even traumatic experiences. “I shall never forgive the doctor and nurse who rendered me helpless, stripping me of my rights, of my dignity as a human being,” one woman recalled. “What should have been the most beautiful moment in my life had become the most horrible. And that is unforgivable.”

This created an opening for midwives to reassert themselves. As a midwife explained, “Women were getting disgusted with getting put to sleep and having a baby dragged out with forceps. It was the perfect time to become a midwife.” Numbers attest to this; between 1970 and 1977, the number of home births doubled in the United States, and the number of nurse-midwifery programs nearly tripled, from seven to 19. Midwives rediscovered and documented the processes of physiological childbirth, reclaiming their expertise in that area.

Nurse midwives, who train in nursing before midwifery, and direct-entry midwives (DEMs), who train directly in midwifery and specialize in out-of-hospital birth, have spent decades advocating for their inclusion in the U.S. health-care system, with tentative and limited success. The creation of the American College of Nurse Midwives (ACNM) in 1955 and the Midwives Alliance of North America (MANA) in 1982 enabled midwives to help establish licensing guidelines and push for midwifery legislation in various states.

They also helped to establish their medical credibility. When direct-entry midwives approached the Kentucky legislature about a midwifery bill in the early 1980s, for example, “they didn’t even know how to pronounce the word midwifery; they didn’t know that we existed, that there was such a thing.”

And so, MANA developed the first national certifying examination for direct-entry midwives and launched a national registry of midwives, which laid the groundwork for the establishment of the certified professional midwife (CPM) credential. Then, when states debated license regulations, legislators understood that “these weren’t a couple of kooks that came up with this idea.”

Convincing obstetricians that midwives should be part of maternity care, however, proved more challenging, as most still agreed with DeLee’s decades-old assessments that midwives were either incompetent, a threat to obstetric practice or both. In 1971, the American College of Obstetricians and Gynecologists and the ACNM approved a “joint Statement on Maternity Care,” marking the first time ACOG recognized nurse-midwifery as a legitimate health profession. The statement called for the “cooperative efforts” of nurses, nurse-midwives, and other personnel working under the direction of obstetricians. But in practice, this meant that midwives could work only “under the direction of obstetricians,” limiting the authority and power they were seeking to gain in the first place.

The state-supported eradication of the American midwife was particularly harmful for women of color, as it contributed to dramatic racial maternal health disparities. With the elimination of community midwives, historically oppressed communities were left without secure access to either midwifery or medical care, and subjected to racism and neglect in the care they receive. A century later, black American women are many times more likely to die in childbirth, or to see their baby die, than the average population.

In short, the degradation of the midwife has coincided with the rise of a health-care system that is expensive, ineffective and unequal, and has left the United States with a higher infant mortality rate than any of the other wealthy countries. While modern obstetrics and emergency medicine are valuable and necessary components of 21st-century birth practices, they should not be viewed as exclusive, or incompatible with midwifery care.

Midwives at home and birthing centers can help deliver favorable birth outcomes during and after covid-19, but this requires addressing the historical biases of obstetricians and health providers that have prevented the integration of midwifery into the health-care system. Doing so would create a maternity care system that allows women to find the safest and healthiest option for them and their babies, whether at home or in the hospital, and have access to a midwife if they need one.