History Midwifery in Texas

Midwifery is one of the oldest professions, with midwives practicing in Texas since the era of the Republic of Texas and even earlier. During the 19th century, attitudes toward midwifery began to shift, and the field of medicine faced its challenges. The 1910 Flexner Report highlighted that 90% of practicing physicians lacked a college education, with obstetrics being the most poorly taught specialty. This report called for the centralization of health education in medical schools.

Formal medical institutions began to promote scientific inquiry and disseminate crucial medical knowledge, such as Pasteur's germ theory, Holmes' and Semmelweis' work on puerperal fever, and Lister's principles of antisepsis. Federal funding through the Children's Bureau further supported medical education, leading to the decline of midwifery education programs, which were seen as informal and unscientific. Traditional midwifery, with its homeopathic and herbal remedies, starkly contrasted with the emerging modern medical practices.

The Decline and Resurgence of Midwifery in America

While midwifery professionalized in Europe and Great Britain, integrating fully into the medical system, the United States experienced a decline in midwifery due to restrictive legislation and public campaigns. By 1915, midwives attended 40% of all births, but this number dropped to 10.7% by 1935, with midwifery becoming associated primarily with the care of the poor, foreign-born, or nonwhite populations.

However, a new form of midwifery emerged in the U.S. Outraged by the inequities in care for indigent families, social activist Mary Breckinridge trained as a nurse-midwife in England and founded the Frontier Nursing Service in 1925, bringing professional midwifery to Appalachia. This led to the establishment of nurse-midwifery schools and the formation of the American College of Nurse-Midwifery (ACNM) in 1955. By 1971, the ACNM began certifying nurse-midwives.

Texas Certified Nurse-Midwives

During the early twentieth century, nurse-midwifery practice opportunities in Texas and the U.S. were limited. Most midwives in Texas were traditional lay midwives, often called Granny midwives or Parteras, who practiced in homes. Nurse-midwives worked primarily in public health clinics, early birth centers, and home births. By the mid-1950s, nurse-midwifery programs began in hospitals for the indigent on the Eastern Coast of the U.S. Before the 1960s, nurse-midwives often served as supervisors and consultants to traditional midwives. Many early nurse-midwives viewed their work as a social mission, with a significant number being Catholic nuns or missionaries. From the start, nurse-midwives documented their effectiveness through quality research.

The legal foundation for Texas midwifery practice was largely unquestioned until the 1956 case of Banti vs. Texas. In this case, the Texas Attorney General ruled that a midwife assisting in childbirth was not practicing medicine since childbirth is a normal function of womanhood, not a treatment for disease. In 1978, the Texas Attorney General clarified that Texas laws distinguished between lay midwives and nurse-midwives, with the Texas Nurse Practice Act regulating nurse-midwives. The Texas Department of Health began to regulate non-nurse midwives. In 1984, the Texas Board of Nursing recognized nurse-midwives as Advanced Nurse Practitioners, later updated to Advanced Practice Nurses. The 1985 Birthing Center Act regulated birth centers, primarily operated by midwives. In 2005, non-nurse midwives were granted the title Licensed Midwife. Texas now recognizes two types of midwives: Certified Nurse-Midwife and Licensed Midwife.

In 1972, Franciscan nun Sr. Angela Murdaugh CNM established Texas's first CNM birth center at Su Clinica Familiar in Raymondville. Subsequent CNM birth centers opened in Harlingen (1977), Brownsville (1980), and Weslaco (1983), serving primarily indigent families. Since the 1980s, more well-educated, middle-class women with insurance have sought midwifery care and a natural, family-centered approach, leading to a growth in birth centers serving the middle class.

The 1980s and 1990s saw a rapid increase in certified nurse-midwives in Texas hospitals. In 1981, a midwifery service was established at Jefferson Davis Hospital in Houston under Susan Wente CNM, and Baylor College of Medicine's Midwifery School opened in 1983-84. By 1990, the Nurse-Midwifery Service moved to Ben Taub General Hospital in Houston, delivering about 900 babies per year by 2006.

Texas Tech Health Sciences Center at El Paso opened a midwifery service in 1981 at Thomason Hospital under Carolyn Rutledge CNM, with the University of Texas/El Paso's first midwifery class beginning in 1991. In Dallas, a large service was established in 1987 at Parkland Hospital under Nancy Jo Reedy CNM, with the Parkland School of Nurse-Midwifery opening in 1989 under Mary Brucker CNM. By 2006, Parkland's nurse-midwives attended about half of the nearly 17,000 annual births.

In Galveston, the University of Texas Medical Branch's nurse-midwives began delivering in the hospital and providing maternity care in the UTMB regional maternal and child health program in 1990, organized by Margaret McGill CNM and Carolyn Nelson Becker CNM. The UT Nurse-Midwifery Education Program in Galveston began in 1992, with CNMs Angelina Chambers, Carolyn Nelson, and Donna La Blanc Morris organizing the program. UTMB employs about 30 CNMs.

These hospital CNM services primarily cared for a large number of indigent maternity patients, but other hospital CNM practices were established to serve well-educated, middle-class women seeking the personal relationship hallmark to midwifery care, natural childbirth, and family-centered care.

Midwifery Education in Texas

The closure of nurse-midwifery educational programs in Texas has been a significant loss. Since 2001, Texas has lost all four of its nurse-midwifery programs. Despite this, efforts continue to establish new educational opportunities, such as the Doctor of Nursing Practice (DNP) program at Baylor and the Master's level nurse-midwifery program at Texas Tech University Health Sciences Center.

The Consortium of Texas Certified Nurse-Midwives (CTCNM)

Recognizing the need for effective statewide communication and unity to eliminate barriers to midwifery care, Texas Certified Nurse-Midwives (CNMs) founded The Consortium of Texas Certified Nurse-Midwives (CTCNM) in January 1980. The state's five American College of Nurse-Midwives (ACNM) chapters were primarily focused on local or national issues and struggled to address Texas-specific concerns such as prescriptive authority, Medicaid and insurance reimbursement, and birth center policies.

The solution came with the establishment of CTCNM by nurse-midwives Nancy Locke, Ann Dignan, Donna La Blanc, Sandy Haldeman, and Sandra Gale. Since the ACNM is not organized along state lines, CTCNM operates as an independent group with its own bylaws, officers, and dues. Meetings are held quarterly and rotate throughout the state.

Today, Texas has over 419 nurse-midwives working in diverse practice settings. They deliver babies in numerous Texas hospitals, including teaching facilities for physicians, military, and private hospitals, as well as freestanding birth centers and clients' homes. Certified Nurse-Midwives also provide primary care in women's health and maternity clinics and private practices.

CTCNM has been instrumental in uniting midwives of diverse backgrounds, promoting safety and professionalism, and advocating for the independent and full-scope practice of nurse-midwifery in Texas. This organization remains crucial in ensuring quality care for women and children and supporting families' choices in childbirth within the bounds of evidence-based care.

Conclusion

The history of midwifery in Texas is a testament to the resilience and adaptability of the profession. Despite significant challenges, midwifery continues to evolve, providing essential care and advocating for the health and well-being of women and children in Texas.

Compiled by: Mary Barnett CNM, MN, with assistance from Mary Brucker CNM, DNSc, and Sister Angela Murdaugh, CNM, past president of CTCNM and the American College of Nurse Midwives. Based on notes from "Midwifery & Childbirth in America" by Judith Pence Rooks, Temple University Press, 1997. Updated January 21, 2008, and February 2014 by C. Stuart.