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Coming Home: How Midwives Changed Birth (review)

It’s a rare academic history book that tempts me to binge-read.  Wendy Kline’s Coming Home: How Midwives Changed Birth is one of those special finds.

Cover for 

Coming Home

Admittedly, Kline writes about a topic I find inherently fascinating: the re-emergence of home birth in the United States in the latter decades of the twentieth century and early decades of the twenty-first.  Kline’s approach is typical of nuanced, heavily-researched academic history in many ways, with topical chapters that provide novel analysis and contribute to the larger literature in the history of reproduction, health care, and women’s rights.  Its special appeal comes from its clear and well-organized writing style that allows the narrative to flow and the arguments to seamlessly emerge, combined with Kline’s evident empathy and affection for the midwives, physicians, and birthing women whose history she locates in a fantastic trove of privately-held documents, institutional archives, and oral histories.

Over the course of the late nineteenth and early twentieth centuries, midwifery nearly disappeared from the American scene, and hospitals became the normative place to give birth.  Middle-class women chose physicians to attend their births, and midwives came under regulatory scrutiny.  While many midwives who served urban immigrants at the turn of the century had been formally trained in Europe, in the United States they were regarded dismissively by physicians’ organizations.  “Granny” midwives continued to serve poor rural African-Americans in the south, under heavily-circumscribed licensure, but they were regarded as a backstop for women too poor to hire a doctor.  Midwives and home births looked like they would become relics of the past.

As Kline shows, though, some the seeds of midwifery’s rebirth were already planted, in some unexpected places, in the decades when birth was gradually moving to the hospital.  Home birth survived in Chicago, provided by the Chicago Maternity Center, founded as the Maxwell Street Dispensary by famed obstetrician Joseph DeLee in 1895.  DeLee is known for his outsized role in moving birth from home to hospital, and yet, because he saw home births as an ideal way to train young doctors, he supervised a robust operation that trained physicians in the skills to attend poor women in their homes.  Some of those physicians would become advocates and mentors for home birth midwives in the 1970s. 

Home birth received another boost from La Leche League, a breastfeeding support group founded in a Chicago suburb in the late 1950s.  La Leche League’s founders were Catholic women who valued large families and saw childbearing and rearing as women’s primary purpose.  Just as they wanted to experience immersive motherhood via breastfeeding, many also regarded natural childbirth as central feminine experience.  This often meant delivering at home, and thus, home birth skills were preserved in the middle-class Chicago suburbs in addition to the inner-city neighborhoods served by the Chicago Maternity Center.

In the late 1960s and early 1970s, a swirl of social changes combined with widespread dissatisfaction with the alienating procedures of typical hospital births provided fertile soil for the emergence of home birth practitioners in many locations simultaneously.  Kline specifically examines the Washington, D.C. area, where childbirth educators led a white, middle-class home birth movement that was largely funneled through the Georgetown University nurse-midwifery training program, as well as the wild and wooly California hippie homebirth scene.  By the time Kline addresses the most iconic of homebirth advocates, Ina May Gaskin, and the anti-war school bus Caravan travels during which Gaskin and her fellow travelers taught themselves midwifery from a manual for third-world rural midwives and the hands-on experience of their own births, it is clear that the homebirth movement was much bigger than just its most colorful figures.  Kline includes mystical, psychedelic births in teepees and school buses, but she situates them in the counterculture’s broader critique of mainstream society and medical culture, in a sensitive and nuanced reading of that counterculture and its place in a larger reaction to dehumanizing medical practice.

Later chapters address homebirth midwifery’s struggles with legal recognition and the challenges of developing a structure for a profession full of practitioners wary of routinization.  A chapter on a sting operation carried out on the Santa Cruz Birth Center in 1974, pitting legal and medical authorities against a successful and popular unlicensed midwifery practice, contains one of the biggest archival treats of the book: material from the diary of Kate Bowland, the midwife at the center of the case.  Kline’s reading of the diary is an insightful peek into the thoughts of a central actor at a moment when midwives’ attempts to weave together their best practices, their spiritual insights, and physician backup broke down under legal pressure.   It is also a powerful homage to historian Laurel Thatcher Ulrich’s iconic close reading of early-nineteenth-century midwife Martha Ballard’s diary in A Midwife’s Tale.  Midwives gain insight and authority from tracing and understanding their lineage; so do feminist historians of birth.

In the late 1970s home birth midwives came together to create their own professional organization, the Midwives Association of North America (MANA), while a group of practitioners in Seattle organized one of the first schools for non-nurse midwives in the United States.  As home birth midwifery developed its institutions, at each step, organizers worked to construct a set of shared commitments, knowledge, practices, and institutional arrangements that they believed would best serve their goal of facilitating safe and meaningful births.  Kline gives her reader a sympathetic picture of earnest and idealistic organizers working through inevitable contention to create organizational structures that would recognize and respect the range of legitimate birth practices its practitioners had developed, while reassuring regulators and birthing families that they were offering high-quality services.

We academics sometimes are tempted to talk over our sources, anxious that without explicit interpretation at every moment, our readers won’t take our point.  Kline knows how to get out of her sources’ way and let them tell their own stories, when she brings them into the narrative.  She uses her oral histories judiciously, with the kind of finesse that lets them shine.

Coming Home is an important book for anyone who cares about the history and future of birth in the United States.  Whether or not we would consider a home birth for ourselves, it is inspiring to understand how home birth midwives sought to improve the experience of birth, dedicated themselves to offering care their clients valued, and worked to create organizational structures to be able to offer consistent, safe, legally-sanctioned care to birthing families across the United States.

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