The History of Midwifery Practice at Massachusetts General Hospital
Editor's Note: The International Conference of Midwives describes the practice of midwifery as optimizing the normal biological, psychological, social and cultural processes of pregnancy, childbirth and the postnatal/newborn period. This includes working in partnership with birthing parents and respecting their individual circumstances and views.
This blog post, which was written by Andrew Glyman, Ann Collins (MGH School of Nursing, Class of 1966) and Christine Rich (MGH School of Nursing, Class of 1973), documents three interconnected stories: The introduction of certified nurse midwifery to the United States; the decades-long effort to legalize Certified Nurse Midwives in Massachusetts; and the successful integration of nurse midwifery at Massachusetts General Hospital (MGH) from 1994 to present.
Through interviews with key participants and historical documentation, the authors trace how MGH transformed from an institution that excluded midwives to one that embraces collaborative midwifery practice as essential to excellent maternity care.
Of Note: Lay midwifes have been successfully delivering babies since ancient times. This paper will concern itself only with the history of Certified Nurse Midwifery in the United States.
Introduction of Nurse Midwifery in the United States
Mary Carson Breckinridge of Kentucky, a registered nurse, is credited with bringing the role of the nurse midwife to the United States.
Mary Breckinridge (image courtesy of Wikimedia commons)
Breckinridge, a well-educated woman, received her midwifery training in England and Scotland.
Once back in the U.S., she established the Frontier Nursing Service (now Frontier Nursing University) in 1925 that provided nurse midwifery care to the poor of Appalachia³.
Between 1933-1955, recommendations were made for the development of nurse-midwifery in the United States.
These recommendations included that nurse-midwifery education should result in the granting of a diploma from a recognized university;, the development of standardized requirements for admission to any nurse-midwifery education program; and the standardization of the curriculum⁴.
Formal nurse-midwifery education programs emerged slowly in the 1930s and 1940s. The Maternity Center Association (now known as the Childbirth Connection) in New York City opened the Lobenstine School of Midwifery in February 1932, the nation's first school dedicated to educating nurse-midwives⁵.
Breckinridge's Frontier Nursing Service established its own educational program in 1939⁶. A significant milestone came in 1956 when Yale University's School of Nursing opened a program in maternal and newborn health nursing⁷, signaling growing acceptance of nurse-midwifery within mainstream academic institutions.
Legalization of Nurse Midwifery in Massachusetts
Massachusetts was one of the last states in the U.S. to legalize Certified Nurse Midwives.
Helena McDonough was one of several dedicated healthcare professionals who contributed to the legislative process that eventually led to the legalization of nurse-midwifery in Massachusetts.
As part of a coalition of nurses, healthcare advocates, and supportive legislators, she participated in hearings and provided testimony that helped inform the policy development process.
After graduating from the MGH School of Nursing in 1966, Helena continued her education at Boston College, and completed her nurse-midwifery education at Yale University in 1975.
Following certification, she established a nurse-midwifery practice in Massachusetts and worked within existing regulations to provide care to women while advocating for formal recognition of the profession.
Beginning in 1975, she gave many lectures and public talks in an effort to develop relationships with the public and the media. This was done to clarify both the differences between unlicensed midwives and CNMs and to stress the importance of legalizing the CNM role.
From 1975 to 1996, Helena provided testimony at the Massachusetts State House Public Hearings, Board of Registration in Nursing, Massachusetts Department of Public Health Labs in Jamaica Plain (MA), Health Care Committee, MA State House, Rate Setting Commissions and Division of Insurance Commission, Boston, MA.
The purpose was to advance the legislative process towards legalizing the practice for Certified Nurse Midwifery in MA.
Over an eight-year period, Helena accomplished the following goals:
- Proposed rules and regulations for CNM practice
- Secured Medicaid reimbursement for CNM
- Proposed rules and regulations for out-of-hospital birth centers
- Secured prescriptive authority and third-party reimbursement
- Initiated a bill to establish a Board of Midwifery
- Developed regulations for CNM prescription writing
In addition, she was instrumental in having birth certificates revised to acknowledge CNM deliveries.
The American College of Nurse-Midwives recognized Helena's professional contributions by inducting her as a Fellow in 1992, an honor that acknowledges significant contributions to the midwifery profession through clinical excellence, education, administration and research.
Reopening of the Obstetrical Service at MGH and the Inclusion of Certified Nurse Midwifes
The Obstetrical Service first appeared at MGH in 1917. However, no obstetrical teaching service was created. Without the quality of care made possible by residents and specially trained nurses, the service struggled, and eventually closed in 1952².
In 1988, Isaac Schiff, MD, was made the new Joe Vincent Meigs Professor of Gynecology at HMS, expanded the resident training experience and discussed with hospital administration the possibility of returning obstetrics to MGH.
By doing so, MGH had the potential to provide cradle-to-grave services for existing patients at one institution rather than sending its patients to other institutions for maternity care.
Dr. Schiff was instrumental in recruiting Frederick Frigoletto, MD, to MGH. Dr. Frigoletto was chief of obstetrics and gynecology at the Brigham and had CMs on his service.
Dr. Frigoletto's vision for MGH was a collaborative practice in which the patient would have a choice of either a CNM or obstetrician, but in the event of a high-risk complication, the patient may avail herself of the subspecialist's expertise without losing contact with the CNM.
Jeanette Ives Erickson served as Director of Nursing Support Services during the reopening process and was instrumental in providing the specially prepared nursing staff for the new unit. The Obstetrical Service opened in 1994⁸.
We interviewed Robin Azevedo, BSN, RN, LPN, a labor and delivery nurse, and Kim Deltano, a CNM, who shared their personal experiences and perceptions working on this newly opened Obstetrical (OB) Service.
Azevedo began her tenure at MGH in 1994, one week before the unit opened its doors, and Deltano joined the service nine months later. Of note, both remained at MGH for nearly three decades.
Azevedo joined the MGH OB service after working as a Labor and Delivery Nurse at a community hospital for two years.
Deltano earned her MSN and nurse-midwifery certification from the University of Pennsylvania in 1989. Her bilingual capabilities in English and Spanish made her particularly valuable for community health center work in Chelsea, Revere and East Boston.
The OB Service’s 1994 reopening represented a carefully orchestrated blend of institutional knowledge and specialized expertise.
"The original hiring plan was that they would hire ten nurses from within MGH and ten nurses from outside that had labor and delivery experience," recalls Azevedo. This strategic approach proved essential during uncertain early days when staff might go several shifts without a delivery.
This downtime was an opportunity to learn from each other. The nurses hired from outside the hospital shared their obstetrical knowledge and the nurses hired from within shared how to get things done in the MGH system.
"One of the beauties of nursing at MGH is that the collaborative idea is allowed to flourish," Azevedo says. Both she and Deltano spoke highly of the culture at MGH, including the focus on teaching.
Azevedo estimates that during that first year the service saw only 200-300 deliveries, far below the eventual goal of 2,500 per year.
Yet this gradual start allowed the team to establish the collaborative culture that would define the MGH OB Service.
Frigoletto's leadership brought a philosophy of "seamless practice" and hand-selected CNMs who had worked with him on a major active management of labor clinical trial at BWH.
In this study, which was published in NEJM, CNMs played a central role in determining the onset of active labor and providing one-to-one support—establishing them as essential partners in both research and clinical care.
As Deltano observed upon joining in 1995, "Nobody had to teach anybody at that hospital to respect CNMs. It was ingrained."
Midwives were part of the morning pass-off and the evening pass-off, with physicians actively seeking their input.
The service grew rapidly, exceeding its goals within a decade, reaching 3,800 deliveries annually before stabilizing around 3,500.
Current State and Role of Nurse-Midwifery Practice at MGH
CNMs now provide care across multiple sites including the main Boston campus, satellite locations in Danvers and Waltham, and community health centers in Charlestown, Chelsea, and Revere, representing significant geographic expansion from the 1994 model.
The service tracks comprehensive quality metrics allowing for continuous quality improvement and comparison with similar institutions.
Currently, approximately 25-30% of the babies born each year at Mass General are delivered by CNMs⁹, with MGH delivering approximately 3,600 babies annually¹⁰.
The service now has 20 CNMs, including four leadership positions: Chief Midwife, Lead Nurse-Midwife, Director of Education, and Director of Mass General Lactation Program, plus 16 practicing CNMs⁹. MGH currently reports that 82% of babies are breastfed at the time of discharge⁹.
The service's superior outcomes align with statewide data showing that hospitals with higher rates of CNM care demonstrate shorter lengths of inpatient stay, lower cesarean and episiotomy rates, and lower overall maternity spending¹¹.
The service maintains a robust educational mission across multiple levels. Midwifery students are integrated into care with patient consent.
Perhaps more transformative, CNMs teach residents alternative delivery techniques rarely seen in traditional training.
Adapting to Changing Demographics and Clinical Challenges
The patient population has shifted significantly since 1994 with a notable decrease in births from young teen mothers. The hospital has also seen an increase in high-risk patients, necessitating infrastructure changes to assist patients with co-occurring conditions such as heart disease.
A Hope Clinic was established specifically for substance use disorder mothers, addressing the complex needs of this vulnerable population.
Individual careers exemplify the program's profound impact. Azevedo remained on the OB service for 27 years before transferring to the Diabetes Research Center (MGH).
Deltano's 29-year tenure at MGH resulted in delivering 1,680 infants—memorably calculated as "6.2 tons of babies."
Subscribe to BenchMarks!
Subscribe to our monthly research newsletter and be the first to know what’s shaking in science at Mass General Brigham. From groundbreaking discoveries to the latest “you-heard-it-here-first” breakthroughs, we’ve got the updates that’ll keep your curiosity grooving.