Midwifery is almost certainly the oldest specialized health practice in human history, with roots that reach far deeper than any written record. Long before the first medical texts appeared in ancient Egypt or Mesopotamia, women were helping other women give birth. The biological realities of human childbirth, which became dramatically more difficult as our ancestors evolved larger brains and narrower pelvises, likely made birth assistance a necessity for survival rather than a cultural luxury. Tracing midwifery’s origins means looking at archaeology, evolutionary biology, and primate behavior alongside the ancient texts most histories start with.
Why Human Birth Demanded Help in the First Place
To understand when midwifery began, you have to understand why humans need help during birth at all. Most mammals deliver their young without assistance. Humans are unusual. The evolutionary changes that allowed us to walk upright reshaped the pelvis in ways that made childbirth progressively more difficult. Over millions of years, our ancestors’ birth canals narrowed while their babies’ heads grew larger. The modern human pelvis, which emerged roughly 200,000 years ago in Africa, features a tight, roughly circular birth canal that forces the baby to rotate during delivery, a process that does not occur in other primates.1PubMed Central. The evolution of the human pelvis: changing adaptations to bipedalism, obstetrics and thermoregulation That rotation means the baby typically emerges facing away from the mother, making it much harder for her to guide the infant out or clear its airway on her own.
This “obstetric dilemma,” as researchers call it, created a strong survival incentive for someone else to be present at birth. Archaeological studies of forager skeletons from southern Africa show a clear sex disparity in early adult deaths: young women died at higher rates than young men, with an odds ratio of about 1.6 for very young adult death in females from the southern Cape region, consistent with the dangers of childbirth in populations without modern medical care.2International Journal of Paleopathology. Discernment of mortality risk associated with childbirth in archaeologically derived forager skeletons Birth was dangerous, and having a skilled attendant could mean the difference between life and death for both mother and child.
Birth Attendance Before Humans
One of the more surprising findings in recent decades is that assisted birth is not entirely unique to our species. Researchers observing bonobos, our closest living relatives along with chimpanzees, have documented female bystanders actively protecting and supporting laboring mothers. In observed births, bonobo females helped during the final pushing stage by performing manual gestures aimed at holding the infant as it emerged.3Evolution and Human Behavior. Is birth attendance a uniquely human feature? New evidence suggests that Bonobo females protect and support the parturient This does not mean bonobos have midwives in any structured sense, but it does suggest that the impulse to assist during birth has deep evolutionary roots, predating the emergence of our own species. If birth attendance behavior exists in a primate lineage that split from ours millions of years ago, it is reasonable to think that some form of birth help has been present throughout human evolutionary history.
The Ancient Near East and Egypt
The earliest written evidence of midwifery comes from the civilizations of Mesopotamia and Egypt, roughly four to five thousand years ago. Mesopotamian medical texts from the second and first millennia BCE describe gynecological conditions and therapeutic rituals for treating them. These texts are not instruction manuals for midwives in the modern sense, but they reveal a sophisticated body of knowledge about female reproductive health and the cultural rituals that surrounded it.4PubMed Central. Fluids, rivers, and vessels: metaphors and body concepts in Mesopotamian gynaecological texts
In ancient Egypt, midwives occupied a recognized role. They served not only as birth attendants but also as carriers of contraceptive knowledge. Egyptian women practiced birth control with little interference from religious or civil authorities, and midwives were apparently the ones who held and transmitted this expertise, likely drawing on observations of which plants affected fertility in domesticated animals.5European Journal of Obstetrics & Gynecology and Reproductive Biology. Reproduction concepts and practices in ancient Egypt mirrored by modern medicine The Hebrew Bible also references midwives directly, most famously in the Book of Exodus, where the midwives Shiphrah and Puah refuse Pharaoh’s order to kill Hebrew male infants. Whether or not this story is historically literal, it reflects a world where midwives were trusted community figures with considerable authority over birth outcomes.
Greece, Rome, and the Codification of Midwifery Knowledge
The classical Mediterranean world produced the first systematic writings about what a midwife should know and do. The most influential was Soranus of Ephesus, a Greek physician practicing in Rome in the second century CE. Soranus wrote extensively about obstetrics and gynecology, and his work included detailed descriptions of the characteristics and skills a midwife should possess.6PubMed. The effect of Soranus of Ephesus on the work of midwives He outlined criteria for competence, described techniques for managing complications, and discussed the qualities of an ideal practitioner. His texts remained influential for centuries.
The Minoan civilization on Bronze Age Crete offers an even earlier glimpse into how deeply midwifery was woven into religious and cultural life. Archaeological evidence points to a “midwifery koine,” a shared set of practices and symbols connected to birth assistance that stretched across the Near East and Mediterranean. This network of interconnected traditions was linked to female therapeutics and, in Crete, to the cult of the midwife goddess Eileithyia.7Religions. The Obstetric Connection: Midwives and Weasels within and beyond Minoan Crete Midwifery in the ancient world was not just a practical trade; it was embedded in religious ritual and spiritual belief systems.
Midwifery in Medieval Europe
Through the medieval period, midwifery continued as a female-dominated practice across Europe, though the written record is patchy. One of the most debated figures in the history of midwifery is Trotula, supposedly a female physician associated with the medical school at Salerno, Italy, in the eleventh or twelfth century. Texts attributed to Trotula circulated widely and became an important source of medical knowledge in medieval Europe, covering topics from gynecology to skin care. However, extensive research has failed to produce concrete evidence that a physician and writer named Trotula actually existed. The books may have been written by multiple authors or misattributed over centuries of copying.8Mersin Üniversitesi Tıp Fakültesi Lokman Hekim Tıp Tarihi ve Folklorik Tıp Dergisi. Trotula, The First Female Physician of Europe: A Historiographical Debate Real or not, “Trotula” represents the deep tradition of women’s health knowledge in medieval Europe, even when that knowledge was transmitted informally or anonymously.
Medieval English manuscripts from roughly 900 to 1500 CE reveal another dimension of midwifery practice: ritual. Charms, prayers, amulets, and prayer rolls were used to manage the dangers of conception and childbirth. These performative rituals circulated through oral and written traditions, evolving over centuries as religious attitudes shifted. While many of the people who recommended or provided these rituals were men, including monks and friars, the practices often fell to women themselves and their female attendants.9PubMed Central. Performative Rituals for Conception and Childbirth in England, 900-1500 Midwifery in this era blended empirical skill with spiritual care in ways that modern medicine tends to separate.
The Myth of the Midwife-Witch
A persistent narrative holds that midwives were specifically targeted during the European witch trials of the sixteenth and seventeenth centuries, persecuted because their reproductive knowledge threatened male authority. This idea has been important to modern feminist movements and to the revival of midwifery in North America. The evidence for it, though, is thin. A detailed examination of the midwife-witch claim found limited support for the idea that midwives were singled out in witch prosecutions.10Canadian Journal of Midwifery Research and Practice. The Midwife-Witch on Trial: Historical Fact or Myth? Some midwives were accused of witchcraft, as were people in many other occupations, but there is no strong evidence of a systematic campaign against them as a profession. The story is more useful as a founding myth of the modern midwifery movement than as a description of what actually happened.
When Men Entered the Birth Room
For most of recorded history, birth was an exclusively female space. That changed in Europe beginning in the seventeenth and eighteenth centuries, when male physicians and surgeons began attending deliveries, a development sometimes called “man-midwifery.” The shift accelerated with the founding of lying-in hospitals, institutions specifically for childbirth. The motives were mixed: some physicians were genuinely interested in improving birth outcomes through new techniques and instruments like forceps, while others were drawn by the professional prestige and income that attending births provided.
The transition to hospital birth came with devastating unintended consequences. Puerperal fever, an infection now known to be caused by bacteria introduced during delivery, was common in mid-nineteenth-century hospitals and frequently fatal, with mortality rates ranging from 10% to 35%.11PubMed Central. Medicine in stamps-Ignaz Semmelweis and Puerperal Fever Ignaz Semmelweis, a Hungarian physician working in Vienna, demonstrated in the 1840s that hand disinfection could drastically reduce infection rates. His findings were largely rejected by the medical establishment during his lifetime. One analysis of the man-midwifery era estimated that hospital-based delivery in Britain and Ireland between 1730 and 1930 resulted in roughly a million more maternal deaths than would have occurred if home births had remained the norm.12PubMed. Man-midwifery history: 1730-1930 The irony is sharp: the professionalization of birth, marketed as progress, was for two centuries deadlier than the traditional midwifery it displaced.
The Hospital Takeover in the United States
The American experience followed a distinctive pattern. In 1900, only about 5% of births in the United States took place in hospitals. By 1935, nearly three-quarters of urban births and half of all births occurred in hospitals.13Explorations in Economic History. From home to hospital: The evolution of childbirth in the United States, 1928–1940 This was not simply a matter of women choosing hospitals over home. A regulatory apparatus was built to push midwifery out of practice, particularly in the South, where African American midwives had long served their communities.
By the early 1920s, the terms “granny” and “granny-midwife” had become synonymous with Black midwives in the rural South. These women served communities where few physicians, white or Black, were willing to attend births for the two or three dollars a midwife would accept. African American mothers also preferred home births to hospital deliveries to avoid the prejudice and discrimination they faced in white-run institutions. Government programs under the Sheppard-Towner Act and later the Social Security Act trained these midwives and used them as health educators in their communities.14PubMed Central. Nothing to Work With but Cleanliness: The Training of African American Traditional Midwives in the South
Yet the regulatory framework that ostensibly aimed to standardize care also systematically dismantled traditional midwifery. Manuals issued by state and federal authorities codified competencies and imposed literacy requirements, documentation burdens, and supervisory oversight that shifted authority from community midwives to state-approved professionals. In states like Alabama, these rules selectively advantaged nurse-led models and embedded racialized assumptions, framing traditional midwives as problems to be corrected rather than as knowledge-holders. The combined effect of tightened licensure, increased surveillance, and narrowing pathways into practice was to diminish traditional midwifery in the South over several decades.15PubMed. Regulating Midwifery Through Manuals: Institutionalization and the Displacement of Traditional Midwives in the 20th-Century South
Indigenous Birth as Ceremony
The medicalization of birth affected Indigenous communities around the world in ways that went beyond just replacing one practitioner with another. Within many Indigenous cultures, birth is a ceremony celebrating new life and acknowledging the passage from the spiritual world into the physical one. Colonial policies disrupted these practices by relocating births to distant hospitals, separating mothers from their communities and cultural supports. While initiatives to “indigenize” health care have been made, advocates argue that international human rights frameworks, including the United Nations Declaration on the Rights of Indigenous Peoples, contain provisions that support the right to incorporate Indigenous childbirth ceremonies into clinical practice.16PubMed Central. Indigenous Birth as Ceremony and a Human Right For these communities, reclaiming birth practices is not nostalgia; it is a matter of cultural survival and self-determination.
What Modern Evidence Says About Midwife-Led Care
The revival of midwifery in high-income countries over the past several decades has generated a substantial body of research. A Cochrane systematic review comparing midwife continuity of care models with standard hospital models found that women receiving midwife-led care were more likely to have a spontaneous vaginal birth (about 70% compared to 66% in standard care) and less likely to have a cesarean section (about 15% versus 16%). Instrumental deliveries with forceps or vacuum dropped from about 14% to 13%, and episiotomy rates fell from roughly 23% to 19%. Women in midwife-led care also reported more positive experiences during pregnancy, labor, and the postpartum period, and cost savings were noted during pregnancy and birth.17PubMed Central. Midwife continuity of care models versus other models of care for childbearing women
A broader scoping review echoed these findings: midwife-led care was associated with higher rates of spontaneous vaginal delivery, fewer labor interventions, and greater maternal satisfaction. Neonatal outcomes were comparable or better, with some studies showing reduced preterm births and fewer admissions to neonatal intensive care.18PubMed Central. Effect of midwife-led care models on maternal and fetal outcomes: A scoping review The improvements are not enormous in absolute terms, but they are consistent across many studies and many countries, which makes them hard to dismiss.
Traditional Birth Attendants in Lower-Income Countries
While high-income countries debate whether midwifery should be integrated into hospital systems, much of the world never stopped relying on traditional birth attendants. In lower-income countries, traditional birth attendants often remain the only accessible option for women in rural areas. The question is not whether to use them but how to connect their work with the formal health system so that complications can be managed when they arise.
Research on integrating traditional birth attendants with formal health systems has identified several mechanisms that work: training and supervising attendants, teaching collaboration skills to health workers, including attendants at health facilities, establishing communication systems for referrals, and clearly defining each person’s role. The impact on skilled birth attendance depends on how attendants are selected, whether communities participate in the process, and whether barriers to reaching facilities are addressed. Successful approaches tend to be highly context-specific.19PubMed. How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance
More recent recommendations have gone further, calling for traditional birth attendants to be integrated throughout prenatal, birth, and postpartum care rather than being limited to a referral role. This includes building their capacity to recognize high-risk situations, creating collaborative pipelines to facility-based care, and establishing inclusive facility environments where attendants are welcome. The goal is to reduce the medical mistrust that prevents many women from seeking facility-based care while preserving the culturally relevant support that traditional attendants provide.20PubMed Central. Recommendations for Integrating Traditional Birth Attendants to Improve Maternal Health Outcomes in Low- and Middle-Income Countries In a sense, this approach circles back to something the oldest midwifery traditions already understood: that birth is a social and cultural event, not just a medical procedure, and that the person helping needs to be someone the mother already trusts.