A History of Texas Nurse-Midwifery and the Consortium of Texas Certified Nurse- Midwives

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Midwifery: one of the oldest professions

Midwives have been in Texas since the time of the Republic of Texas and even long before that. In the nineteenth century however, attitudes changed towards midwifery. Medicine had its problems too. In 1910, the Flexner report noted that 90% of practicing physicians were not college educated and among all the specialties the most poorly taught was obstetrics. There was a national call to centralize health education in medical schools. Formalized medical communities and universities facilitated scientific inquiry, and disseminated new information such as Pasteur's theory of infectious diseases, Holmes' and Semmelweis' work on childbirth-fever, and Lister's writings on antisepsis. Federal funds through the Children's Bureau began to support medical schools in an effort to educate physicians.

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The focus to establish and improve American medical schools was to the detriment of midwifery education and most existing midwifery education programs were closed. American midwifery then became almost exclusively informal. Scientific discoveries and medical advances in pharmacology, and other practices were implemented routinely in obstetrics, without integration into midwifery. Homeopathic & herbal remedies and traditions practiced by generations of midwives starkly contrasted to more "modern" remedies of physicians. Modern American women wanted to right to vote and the right to be relieved of pain in childbirth. American midwifery became a profession of & by the poor.

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While professional midwifery declined in the United States, midwifery professionalized in Europe and Great Britain during the late 19th Century. Midwifery was completely integrated into the medical system on the Continent™. In the United States there grew a perspective that there existed a midwife problem. The knowledge and profession of midwifery of untold centuries almost disappeared in the United States in less than three decades by restrictive legislation and effective public campaigns. Yet midwifery did not totally vanish from the United States. Traditional midwives continued to care mainly for the poor. The practice of midwifery became almost exclusively associated with care of the foreign born or the nonwhite. The poor outcomes that existed were most probably attributable to poverty, lack of public health measures, and access to good medical care were justification to eradicate American midwifery. In 1915 midwives attended 40% of all births. However, by 1935, that number had decreased to 10.7%, of whom 54% were nonwhite. While traditional midwifery began its marked decline, a new type of midwifery was developing in the United States.

Emergence of the Certified Nurse-Midwife

Outraged by inequities in care for indigent families, social activist Mary Breckinridge traveled to England to be trained as a nurse-midwife. In 1925 she returned to form the Frontier Nursing Service, bringing professional midwifery and nursing care to the poorest of the poor in the U.S. in Appalachia. In 1931 the Lobenstine Clinic opened to educate nurse-midwives to care for disadvantaged women in New York City slums. More nurse-midwifery schools were opened and nurse-midwives dispersed through out the country. The American College of Nurse-Midwifery was chartered in 1955, and in 1968 this organization combined with the American Association of Nurse-Midwives to form the American College of Nurse-Midwives (ACNM). In 1971, the ACNM began certifying nurse-midwives, one of the first organizations to establish such a process for nurses. Texas Certified Nurse-midwives (CNM) have their origins in these roots and are educated in the two distinct professions of nursing and midwifery.

Texas Certified Nurse-Midwives

During the early twentieth century, opportunities for nurse-midwifery practice in Texas and the U.S. were limited. Most midwives in Texas during this period were traditional-lay midwives and practiced in homes. These midwives were often called Granny midwives or Parteras. Nurse-midwives practiced primarily in public health clinics, early birth centers, and home births. Nurse-midwifery programs in hospitals for the indigent began in the mid 1950s on the Eastern Coast of the United States, and prior to the 1960s nurse-midwives often functioned as supervisors and consultants to traditional midwives. Most early nurse-midwives had a sense of midwifery as a social mission; many were Catholic nuns or missionaries. From the beginning nurse-midwives documented their efficacy/outcomes with quality research.

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The legal basis for Texas midwifery practice was never questioned until Banti vs Texas in 1956. In this case the Texas Attorney General ruled that a midwife who aided a woman in birth was not practicing medicine. Childbirth is a normal function of womanhood furthermore assistance in childbirth was not the treatment for a disease nor did it effect a cure. In 1978 Texas Attorney General wrote that the laws of Texas do distinguish between the practice of lay-midwives and nurse-midwives, and further that the Texas Nurse Practice Act regulated nurse-midwives. The Texas Department of Health began to regulate non nurse-midwives. In 1984 the Board of Nursing in Texas recognized nurse-midwives to practice as Advanced Nurse Practitioners. Later this designation was changed to current one of Advanced Practice Nurse. In 1985 the Birthing Center Act was enacted by the Texas legislature to regulate birth centers, which are primarily operated by midwives. In 2005 after decades of professional development, the non nurse-midwives were granted the title Licensed Midwife. Texas currently recognizes two different types of midwives the Certified Nurse-Midwife /Advance Practice Nurse and the Licensed Midwife.

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Franciscan nun, Sr. Angela Murdaugh CNM established Texas™ first CNM birth center in 1972 at Su Clinica Familiar in Raymondville. CNM-birth centers followed in Harlingen at Su Clinica Familiar in 1977, Brownsville at the Brownsville Community Health Center in 1980, and Weslaco at Holy Family Birth Center in 1983. These CNM birth centers served primarily indigent families. It is of interest that since the 1980s increasing numbers of birth center clients are well-educated, middle class women with insurance who desire midwifery care, and a natural, family centered approach. A growing number of birth centers in Texas serve primarily the middle class.

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In 1974 Sr. Angela, along with CNMs: Sr. Gertrude Welsh, Joan Hoffmaster, Sr. Olivia Pendergast, and Sr. Patricia DeBleck formed Texas™ first ACNM Chapter. As the number of nurse-midwives in Texas grew, more chapters were formed. Texas currently has five ACNM chapters. South Texas: Rio Grande Valley and Corpus Christi Central Texas: Waco, Ft. Hood, Austin, San Antonio South East Texas: Houston, Bryan/ College Station, Nacogdoches North Texas: Dallas, FT. Worth, Tyler West Texas: El Paso, Midland/Odessa, Lubbock.

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The 1980s and 1990s saw a rapid rise in the number of Texas certified nurse-midwives in hospitals. In 1981 a midwifery service was established at Jefferson Davis Hospital in Houston under the direction of Susan Wente, CNM. In 1983-84 Baylor College of Medicines Midwifery School organized and opened under her direction. In 1990 the Nurse-midwifery Service at Jeff Davis moved to Ben Taub General Hospital in the Houston Medical Center. In 2006,the nurse-midwives at Ben Taub delivered about 900 babies per year.

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Texas Tech Health Sciences Center at El Paso opened a midwifery service in 1981 at Thomason Hospital under the direction of Carolyn Rutledge CNM and the affiliated University of Texas/ El Pasos first midwifery class began in 1991 under her direction.

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In Dallas a large service was established in 1987 at Parkland Hospital with Nancy Jo Reedy CNM as its director. The Parkland School of Nurse-midwifery opened in 1989, directed by Mary Brucker CNM. Parkland has one of the busiest maternity units in the United States where nurse-midwives in 2006 attended about half of the almost 17,000 births per year. There are about 40 CNMs in the Parkland Memorial Hospital/Dallas County Health and Hospital District.

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In Galveston, the University of Texas Medical Branchs nurse-midwives began delivering in the hospital and providing maternity care in UTMBs regional maternal & child health program in 1990 organized by Margaret Mc Gill CNM and Carolyn Nelson Becker CNM. The UT Nurse-midwifery Education Program in Galveston began in 1992, as a cooperative venture of the University of Texas Medical Branch and The University of Texas at Houston. CNMs Angelina Chambers, Carolyn Nelson, and Donna La Blanc Morris organized this program. UTMB has about 30 CNMs on staff.

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These hospital CNM services were established to care for an overwhelming number of maternity patients, primarily indigent. Other hospital CNMs practices have been established to serve well educated, middle class women with insurance that want the personal relationship that is hallmark to midwifery care, or natural childbirth and, family centered care.

Closure of Texas Nurse-Midwifery Schools

Nurse-midwifery education in Texas has recently experienced significant losses. Since 2001, Texas has lost all four of its nurse-midwifery educational programs. The closure of these programs occurs at a time when 10% of births in the U.S. are attended by a CNM, the ages of CNMs are increasing and the demand for nurse-midwifery is at an all time high. In 2004 Baylor in Houston graduated its last midwifery student. Texas Tech/University of Texas El Pasos last class was in 2004, and the University of Texas Galvestons Nurse-Midwifery Program graduated its last class in 2005. The Parkland School of Midwifery also closed its nurse-midwifery education program in 2006. Parkland's Mary Brucker CNM, DNSc and Mary Ann Faucher CNM, Ph.D have moved to Dallas™ Louise Herrington-School of Nursing at Baylor to establish a Doctor of Nursing Science (DNP)-CNM program. The first students are being admitted in 2007. Texas Tech University Health Sciences Center started a Masters level nurse-midwifery distance education program based out of Lubbock, Texas in 2010 and graduated their first class in 2011 after receiving full accreditation in 2012 under Program Director Christine Stuart, MSN, CNM, WHNP-BC.  Many ask why all four of Texas™ nurse-midwifery programs have closed in less than a decade. Good Question.

The Consortium of Texas Certified Nurse-Midwives (CTCNM)

Texas CNMs recognized the need for effective statewide communications and unity in their efforts to eliminate barriers to midwifery care. Texass five ACNM chapters tended to be focused on either local or national issues and had not able to address Texas issues as a whole such as prescriptive authority, medicaide and insurance reimbursement, and birth center policies. The solution was the creation of The Consortium of Texas Certified Nurse-Midwives (CTCNM) in January 1980. Nurse-midwives Nancy Locke, Ann Dignan, Donna La Blanc, Sandy Haldeman, and Sandra Gale began the organization. Since ACNM was not organized along state lines, CTCNM is an independent group with its own bylaws, officers, and dues. Meetings are quarterly and rotate throughout the state. Each ACNM chapter has a representative to CTCNM that reports on local issues, works on various committees, and reports back to their chapters on statewide initiatives. CTCNM was not created to compete or replace ACNM, but to facilitate the important political work on statewide nurse-midwifery issues.

Texas currently has over 419 nurse-midwives who work in a wide variety of practices. Nurse-midwives 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 provide primary care in womens health and maternity clinics and private practices.

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The geographic size of Texas and the importance of Texas politics on law and policies affecting midwifery, ongoing efforts by some professional organizations to restrict or eliminate midwifery practice, the continuing need by women and children for quality maternity and midwifery services, and the diversity of nurse-midwifery practices reinforces the importance of our statewide organization, CTCNM.

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CTCNM initiatives have included political action, statewide communications, birth center rules and regulations with the Texas Department of Health, ongoing compilation of Texas nurse-midwifery statistics, a partnership with the March of Dimes, and a CTCNM web site. In 1990, CTCNM joined Texas advanced practice nurse specialty organizations: Texas Nurse Practitioners, Texas Association of Nurse Anesthetists, Texas Clinical Nurse Specialists and others to create the Coalition for Nurses in Advanced Practice (CNAP). This organization has unified the voice of Texas Advanced Practice Nurses. Together with CNAP, CTCNM is helping to eliminate barriers for all categories of Advanced Practice Nurses and increase access to quality care. Since inception CNAP has lobbied for prescriptive privileges, and fair reimbursement. CNM Elaine Brightwater was one of the founders of CNAP.

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In 1997, CTCNM hosted the first Gathering of Midwives; this annual retreat includes Texas™ CNMs and Licensed Midwives, completely separate and distinct branches of midwifery. The purpose of the Gathering is to promote unity, erase the gaps and misunderstandings that exist between midwives of diverse backgrounds, and promote safety and professionalism.

CTCNMs primary purpose is to promote and improve healthcare outcomes for the women and children of Texas. CTCNM advocates for the independent and full scope practice of Texas nurse-midwives in the health care system as an ideal way of, achieving safe, high quality, cost effective, and satisfying care for women and children. CTCNM also supports women and families™ freedom to chose with whom and where to have their baby within the safety bounds of evidenced based care.

 

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 
Notes from Midwifery & Childbirth in America by Judith Pence Rooks, Temple University Press, 1997
January 21, 2008; Updated February 2014 by C. Stuart