The evolution of professional obstetric nursing in the United States (1880′s-present): Qualitative content analysis of specialty nursing textbooks

Abstract

Background

Professional maternal-newborn/obstetric nursing in the United States emerged in the mid- 19th century coinciding with the increased medical management of childbirth. Before this mothers were attended by female family members, friends, neighbors and lay nurses or midwives.

Objective

To trace the evolution of professional maternal-newborn/obstetric nursing since its inception, identify factors which may have influenced this evolution, and consider how this knowledge can inform current issues and challenges in caring for childbearing families.

Methods

Qualitative content analysis, informed by historical research methods, was used to analyze selected content from a sample of maternal-newborn/obstetric nursing textbooks published from the 1880′s to the present.

Findings

The last 150 years have been characterized by vast changes in medicine, technology and the healthcare system which have all influenced the evolution of professional maternal-newborn/obstetric nursing. Over the decades there has also been a significant change in the conceptualization of pregnancy/childbearing and our relative understanding of maternal and infant vulnerability. Findings revealed, however, that over time the primary focus of professional maternal-newborn/obstetric nursing care has consistently been: “protection, counseling/teaching and support” of childbearing families. In the U.S. maternal-newborn/obstetric nurses currently face many challenges including caring for an increasingly diverse patient population within a complex, technologically advanced healthcare system. This system is characterized by a high rate of cesarean section births, frequent intervention in vaginal births, disparities in access to care, and a high rate of preventable morbidity and mortality.

Conclusions

Since its origins the nursing profession has matured and nursing's allegience is now clearly to patients and society Today's nurses have the opportunity to play a key role in advocating for healthcare reform which would allow for less interference in the natural birth process, maximize patient outcomes, decrease inequities, and make comprehensive care for all mothers and infants a national priority.

What is already known about this topic?

• •Scholars have written about the history of childbirth in America and the care of maternal-newborn obstetric patients during various historical periods.
• •Nursing scholars have yet to analyze professional nursing textbooks in order to trace their portrayal of the evolution of maternal-newborn/obstetric nursing, and consider what fresh insight these might provide.

What this paper adds

• •For decades the professional nursing of childbearing women and infants was perceived as lacking prestige, but over time it has gained the dignity it deserves.
• •The consistent focus of professional maternal-infant/obstetric nursing care over time has been the protection, counseling/teaching and support of childbearing families.
• •Childbearing was once considered dangerous, but now it is understood as both a normal, family-centered physiologic event, and a developmental transition.
• •For nearly a century maternal-newborn/obstetric nursing textbooks authors have recognized that high quality care throughout the childbearing experience is not equally available to all mothers and infants, and preventable morbidity and mortality is too high.

1. Background

Prior to the 19th century most American women delivered their infants at home attended by female relatives, friends, neighbors, and when available lay midwives (Scholten, 1985; Walzer Leavitt, 2016). It has been widely speculated that the movement toward the medical management of birth was driven by the promise of safer, faster, and less painful deliveries. These promises were made based on such “scientific” innovations as obstetrical forceps, aseptic practices, and the use of chloroform and ether (Scholten, 1985; Walzer Leavitt, 2016; Wertz and Wertz, 1989).

Nurse scholars have explored both the history of childbirth in America (Scholten, 1985; Walzer Leavitt, 2016; Wertz and Wertz, 1989), and nursing care of mothers and infants during various historical periods (Martell, 2000; Rinker, 2000; Walzer Leavitt, 1998). They have yet, however, to analyze professional maternal-newborn/obstetric nursing textbooks and consider what fresh insight these might provide related to the past and future of this nursing specialty.

In the United States (U.S.) the earliest maternal-newborn/obstetric nursing textbooks were published during the late 19th and early 20th century, coinciding with the dawn of professional nursing and the medical management of childbirth (D'Antonio, 2010; Dock and Stewart, 1938; O'Dowd and Philipp, 1994; Walzer Leavitt, 2016; Wertz and Wertz, 1989). Their purpose was to outline foundational obstetric principles/ knowledge and explicate the role of the professional nurse (DeLee, 1916; Fullerton, 1895; Worcester, 1880). In this paper selected content from textbooks published in the 1880′s to the present was analyzed in order to address the following question: How did professional maternal-newborn/obstetric nursing in the United States evolve over time, from its inception to the present, and what factors influenced this evolution?

2. Methods

A macro-historical, socio-scientific perspective was adopted in undertaking this work. Methodologically, qualitative content-analysis (Drisko and Maschi, 2016; Schreier, 2012), informed by historical research methods (Brundage, 2013; De Chesnay, 2015; Lewenson and Herrmann, 2008), was used to address the primary question. Drisko and Maschi (2016) describe qualitative content analysis as a “systematic method for searching out and describing meaning within texts” (p. 86). It is constructivist in nature and the goal is to identify patterns and regularities in data through the use of inductively and/or deductively derived coding (Drisko and Maschi, 2016). It seeks to explicate new meanings, create new awareness/sensitivity, and enlarge understanding related to the questions posed (Drisko and Maschi, 2016).

2.1. Sampling

A sample of available maternal-newborn/ obstetric nursing textbooks, published in the U.S. from the mid-19th century to the present, served as the primary data sources for this investigation. As appropriate to historical inquiry and qualitative content analysis this sample was both purposive and iterative (Drisko and Maschi, 2016). Initially, historical textbooks were identified by searching the WorldCat Firstsearch database (1800–2005) and the index of the HATHI TRUST using the terms “maternity” “obstetric” and “nursing.” In addition, the 1912 National Union Catalog of Books in Print and the 1972 Bowker's Medical Books in Print were searched by hand. Once potentially relevant books were identified as many as available were retrieved through library services, or by periodically searching and purchasing these or other related texts on Ebay or Amazon.com. More recent nursing textbooks were identified in library holdings, donated by colleagues, or found in used book stores. Ultimately the sample was limited by both availability and feasibility.

Early on, in order to analyze content from books with a similar scope, the search for textbooks was narrowed to comprehensive nursing texts related to childbearing women and newborns. The following were thus excluded: maternity/pediatric books, practical nursing or condensed books, texts specific to only obstetric, GYN or newborn nursing, and nurse midwifery textbooks. To maximize representativeness and protect against bias in primary sources (Brundage, 2013; Lewenson and McAllister, 2015), books from a variety of publishers and authors were sought, and multiple editions of the same book were avoided when others were available. In the end it took approximately a year to obtain a sample which included five to seven books from each of four designated time periods (see Table 1). The first of these time periods, the mid-1880′s to 1920′s, represents the initial emergence of the professional obstetric nurse in the pre-hospital era. The remainder of the time periods: 1930′s −1950′s, 1960′s −1980′s, and 1990′s to present, represent approximately 30 year increments deemed by the author to be representative of logically distinct periods in the evolution of professional obstetric nursing based on a cursory review of the available textbooks. This was deemed a sufficiently large and diverse sample to address the research question, an established criteria for addressing the adequacy of a sample for qualitative content analysis (Drisko and Maschi, 2016).

Table 1.

Overview of maternal-newborn/obstetric nursing textbooks in sample.

Title / Date	Author	Intended Readers	Objective
Time period: 1880′s – 1920′s
Monthly Nursing (1886) # of chapters – 10 # of pages – 250 Publisher: D.W. Mason	A. Worcester MD	For the student nurse in this new profession (From lectures at Boston Lying-In Hospital in Boston and the Waltham Training School)	To set forth principles of obstetrics . . . and describe kind of service . . .can expect from the trained monthly nurse (p. iv)
A Handbook of Obstetric Nursing for Nurses, Students and Mothers 4th ed. (1895) # of chapters – 12 # of pages - 254 Publisher: P.W. Blakiston, Son & Co.	A.M. Fullerton, MD (female physician)	Chiefly written for the student nurse and trained nurse but may help physicians or mothers to understand scientific nursing (From instruction at Woman's Hospital of Philadelphia)	Describes methods to avert dangers of childbirth and early infant life. . . cleanliness, antisepsis and eternal vigilance; and . . .knowledge of conditions . . .nurse may be called upon to manage (p. ix)
A Nurse's Handbook of Obstetrics for Use in Training Schools (1903) # of chapters – 26 # of pages - 391 Publisher: J.B. Lippincott	J. Brown Cooke, MD	Written for the pupils of the New York City Training School for Nurses	“. . .to contain all of the science and art of obstetrics… to practice…in an intelligent manner . . .as a scientifically educated woman . . .with principles and practice of maternity nursing” (p.2)
Title / Date	Author	Intended Readers	Objective
Obstetrics for Nurses (1916) (4th ed.) # of chapters – 7 # of pages - 508 Publisher: W.B. Saunders Co.	J. B. DeLee AM, MD	Intended primarily for nurses although medical students may find value in it. (Outgrowth of lecturing in 4 training schools) (p. 9)	“The treatment in this book is not to take the place of the doctor's orders . . . the book will be of help when she [the nurse] is on her own . . . or for general information” (p. 20) and to help her “spreading the gospel of good obstetrics” (p. 19)
Obstetrics for Nurses (1917) # of chapters – 25 # pages – 374 Publisher: C.V. Mosby	C. B. Reed MD	For class instruction and post-graduate reference for the professional nurse	“This book represents the obstetric ideas and technic which the writer has endeavored to impress upon his students and nurses with such recommendations and changes as experience and scientific progress have suggested” (p. 9)
A Text-book of Obstetrical Nursing (1922) # of chapters – 10 # of pages - 291 Publisher: Lea & Febiger	A. Weld Tallant MD (female physician)	Nurses (Outcome of teaching nurses at the Hospital of the Woman's Medical College of Pennsylvania)	“. . . as a background for the more practical part of their [nurses] training . . . also emphas on the human side of obstetrical nursing. . . the watch-word is service” (p. vi)
Title / Date	Author	Intended Readers	Objective
Obstetrics for Nurses (1923) # of chapters - 20 # of pages - 410 Publisher: D. Appleton & Co.	E. D. Plass, MD	Nurses	To present the “scientific side” of the specialty . . . to provide a better background for the nurses’ practical work. Also to educate trained nurses to assist medical men to dispel ignorance and join the campaign for preventive medicine (p. viii)
TIME PERIOD: 1930′s – 1950′s
Obstetrical Nursing (1934) (3rd ed.) # of chapters – 25 # of pages - 651 Publisher: Lippincott	C. C. Van Blarcom, RN	Nurses and those training in maternity nursing	To “widen the outlook of all nurses, no matter where or by whom trained” and to “describe the underlying principles of obstetrical nursing and offer a survey of . . . nursing methods (p. xv)
Nurses Handbook of Obstetrics (1934) (4th ed.) # of chapters – 21 # of pages - 538 Publisher: Lippincott	L. Zabriskie, RN	Teachers and pupil nurses	“To provide . . . practical source of routine principles and practices of nursing arts in relation to the specialty of medicine in hospitals and in homes” (p. vii)
Title / Date	Author	Intended Readers	Objective
Obstetrics for Nurses (1942) (12th ed.) # of chapters – 12 # of pages - 651 Publisher: Saunders	J. B. DeLee AM, MD M. C. Carmon, RN	Obstetric nursing students, instructors, nurses, nurse-midwives and missionaries.	“. . .this book will be of help to her [the nurse] when she is on her own. . . and for her general information” (p.5). “Principles” of obstetrics are described so she may be equipped “for any condition she may meet” (p.4)
Obstetric Management and Nursing (1954) (5th ed.) # of chapters – 36 # of pages – 836 Publisher: F.A. Davis	H. L. Woodward, MD B. Gardner, RN R. D. Bryant, MD A. E. Overland, RN	The student nurse and obstetric nurse	To provide knowledge, at the level of general principles, necessary for the intelligent management of obstetric cases by the nurse, the doctor's “on-the-scene representative”
Family-Centered Maternity Nursing (1958) Publisher: G.P. Putnam's Sons (Not a comprehensive textbook)	E. Wiedenbach RN, MA, CNM	For parents-to-be but especially “for the nurse and the nursing student who aspires to be an expert in the field of maternity nursing,” (viii) as well as teachers of nursing, obstetricians and hospital administrators (p. viii)	Presents “guiding principles, basic facts and concepts as well as working tools to use in family-centered maternity nursing” (xvi). It also “makes clear how important supportive nursing is and of what it consists” (p. viii)
Title / Date	Author	Intended Readers	Objective
TIME PERIOD: 1960′s – 1980′s
Textbook of Obstetrics and Obstetric Nursing (1963) (4th ed.) # of chapters – 39 # of pages - 577 Publisher: Saunders	M. M. Bookmiller, RN G. L. Bowen, AB, MD	The student nurse	“. . . a practical teaching device and not a reference book” with emphasis on the patient as an individual with potential physical and emotional problems (p. viii)
Obstetric Nursing (1965) (5th ed.) # of chapters – 25 # of pages – 790 Publisher: Macmillan	E. Ziegel BS, MA, RN C. C. Van Blarcom, RN	Primarily for students in nursing or as an up-to-date reference for professional nurses (p. v)	A book focused on current nursing practice based on underlying principles of obstetric care (p. v)
Maternity Nursing (1978) (3rd ed.) # of chapters - 23 # of pages – 578 Publisher: Mosby	C. Lerch RN, BS V. J. Bliss RN, BSN, MSN	Student nurses	“. . . meet . . .need of the student nurse for an up-to-date authoritative text on maternity and neonatal nursing” (p. vii)
Title / Date	Author	Intended Readers	Objective
Maternity Care the nurse & the family (1981) (2nd ed.) # of chapters – 38 # of pages – 1012 Publisher: Mosby	M. Duncan Jensen, RN, MS R. Benson MD I.M. Bobak RN, MS	Nurses, students, and practitioners	Promote and sustain nurses to provide competent, sensitive and individualized support to parents, infants and significant others (p. ix)
Maternity Nursing (1983) (15th ed.) # of chapters – 46 # of pages – 1151 Publisher: Lippincott	S. J. Reeder RN PhD L. Mastroianni, Jr. MD L. L. Martin RN, MS, Dr PH	Students	Provide . . . “a broad conceptual base which the student nurse must have in order to deliver high-quality nursing care to families” (p. ix)
TIME PERIOD: 1990′s - Present
Maternal-newborn Nursing Theory and Practice (1997) # of chapters – 40 # of pages – 1679 Publisher: Saunders	F. H. Nichols, PhD, RNC E. Zwelling PhD, RN	Students and nurses	Guide to maternal-newborn care . . .scientific research and theoretical basis that promote consistent approaches. . . fostering insight. . . essential . . .individualized care (p. xi)
Maternal-Infant Nursing care (1998) # of chapters – 30 # of pages – 906 Publisher: Mosby	E.J. Dickason RN, MA, MED B. Lang Silverman RNC, MS, NNP J.A. Kaplan RN, ACCE, PhD	Student nurses	“…prepare . . . for new roles, emphasizing assessment, client education and home care. . . and the impact of . . . cultural background and family” (p. ix)
Title / Date	Author	Intended Readers	Objective
Maternity & Women's health care (2007) (9th ed.) # of chapters – 41 # of pages – 1188 Publisher: Mosby Elsevier	D. Leonard Lowdermilk RNC, PhD S. E. Perry RN, PhD	Student nurses (also can serve as a reference for the practicing nurse)	Text developed to “provide students with the knowledge and skills they need to become clinically competent, think critically, and attain the necessary sensitivity to become caring nurses” (p. ix)
Foundations of Maternal-newborn and Women's health n 5th Ed. (2010) # of chapters - 34 # of pages – 1034 Publisher: Saunders Elsevier (Includes women's health)	S. Smith Murray MSN, RNC E. Slone McKinney MSN, RNC	Nursing students	“Our text tries to help the student learn to balance “high touch” care with “high-tech,” often life-saving, care” (p. vii). “Our objective . . .to present complex material as simply and clearly as possible” (p. vi)
Olds’ maternal-newborn nursing & women's health across the lifespan (2016) # of chapters – 37 # of pages – 1095 Publisher: Pearson/Prentice Hall	M. R. Davidson PhD, CNM, CFN, RN M. L. London RNC, MSN, APRN, CNS, NNP P. A. Wieland Ladewig PhD, RN	Nursing students	“We remain committed to providing a text that is accurate and readable – a text that helps students develop the skills and abilities they need to know now and in the future in an ever-changing healthcare environment” (p. viii)

2.2. Analysis

The iterative qualitative content analysis steps outlined by Schreier (2012) guided this investigation: “1) Deciding on your research question 2) Selecting your material 3) Building a coding frame 4) Dividing your material into units of coding 5) Trying out your coding frame 6) Evaluating and modifying your coding frame 7) Main Analysis [looking for themes and patterns] 8) Interpreting and presenting your findings” (p. 6). The “primary unit of analysis” in this project was the temporal categorization of textbooks. Initially data from each time period was analyzed, then the data was analyzed as a whole. This allowed for an understanding of patterns of change over time to emerge.

Due to the conceptual nature of the question and the didactic and informational quality of textbooks, analysis was limited to the “other” sub-units of text which included the “preface” and “introductory” chapters of the selected textbooks. See Table 2 for an overview of the full framework for analysis utilized. Due to the importance of context in both historical research and qualitative content analysis additional primary and secondary sources were integrated into the report of findings to facilitate greater understanding (Brundage, 2013; Lewenson and McAllister, 2015; Schreier, 2012).

Table 2.

Framework for qualitative content analysis of maternal-newborn/obstetric nursing textbooks (based on Schreider, 2012).

*Focus of the current analysis.

**Derived inductively from textbooks.

2.3. Rigor

Rigor was addressed using standard criteria for qualitative inquiry as described by Guba and Lincoln (1981) and Lincoln and Guba (1985). The credibility and dependability of the data were addressed in a number of ways. As suggested by Schreier (2012) when only one researcher is coding, all data was re-coded multiple times, following a minimum of 2 weeks from the initial coding. In addition, the data was re-read multiple times by the author, both before and after the initial analysis was completed, to assure no major patterns or themes were overlooked. To support auditability an example of coding specific to the conceptualization of pregnancy and childbirth (1880′s – 1920′s) is provided in Table 3. Finally, the explicitly outlined framework for analysis and the report of findings presented in a rich, highly referenced narrative, further support the overall trustworthiness of findings.

Table 3.

Example of Coding related to the Conceptualization of Pregnancy and Childbirth 1880′s – 1920′s.

Dimension/Category: Conceptualization of Pregnancy/ Childbirth: 1880′s-1920′s
Reference	Selected Relevant Data	Associated Code(s)
Fullerton (1895)	Attention is needed in “averting the dangers of childbirth and reducing the mortality of early infancy” (p. ix); The young infant's “hold on life in the early days of its existence is slender” (p. ix)	Risk/Danger Protection/Prevention
Brown Cooke (1903)	“No woman should die or even be seriously invalided as a result of pregnancy if she is under proper care from the beginning of gestation” (p.14)	Risk/Danger, Protection/Prevention
DeLee (1916)	“Thousands of women enter our hospitals each year for the repair of injuries acquired during delivery” (p.17); “Statistics show that of every 250 women who become pregnant, at least 1 dies” (p. 17); “The people are allowed to believe that labor is a natural process and requires no special care” (p. 2)	Risk/Danger, Societal Impact
Reed (1917)	“Childbirth is a peril” (p. 8)	Risk/Danger
Weld Tallant (1922)	During the “dangerous first month of life. . . many infants slip away” (p. 18)	Risk/Danger
Plass (1923)	“Prophylactic medicine has done much good” and a properly managed labor is no longer “particularly dangerous” (p. 2)	Risk/ Danger, Protection/ Prevention

3. Findings

The professional nursing of childbearing women and infants has morphed since its’ inception in the mid 1800′s. During analysis themes inherent in the evolution of professional maternal-newborn/obstetric nursing during each of the four designated time periods were identified which clarify the context within which certain components of the role remained consistent and others changed. Data revealed that the primary focus of professional maternal-newborn/obstetric nursing care over time has been: “protection, counseling/teaching and support” of childbearing families (see Table 4). In addition, a significant change over time in the conceptualization of pregnancy/childbearing was identified as a major factor which influenced the evolution of this role. The narrative which follows elucidates these findings and further explores and describes how the role has evolved into its modern day manifestation.

Table 4.

Summary of themes by time period inherent in the evolution of professional maternal-newborn/obstetric nursing in the U.S.

3.1. Mid 1880′s - 1920′s: birth of the professional obstetric nurse

The earliest obstetric nursing textbooks heralded the advent of the “professional” obstetric nurse (Brown Cooke, 1903; Reed, 1917; Worcester, 1880), also known as the “trained” obstetric nurse (Fullerton, 1895; Brown Cooke, 1903).1 The professional obstetric nurse was presented as distinctly different from the lay nurse, and said to practice based on scientific principles (Browne Cooke, 1903; Fullerton, 1895). She was applauded as a “blessing,” “glorious advance,” (Worcester, 1880), and one who would greatly benefit humanity (Brown Cooke, 1903; Weld Tallant, 1922; Worcester, 1880).

3.1.1. Nurses extend the reach of the obstetrician

Obstetrician H.M. Stowe (1910) argued that since doctors had begun to specialize in obstetrics there was a corresponding need for specially trained obstetric nurses. He claimed that without the nurses’ assistance the doctor was “handicapped” and “unable to do his work” (p. 554). The professional nurse was described as one who “supplements” medicine (Worcester, 1880), and acts as an “aid” (DeLee, 1916) or an “associate” of the physician (Reed, 1917). Brown Cooke (1903) famously drew an analogy to the army and referred to the professional nurse as a “lieutenant” and the doctor as the “captain” or “colonel.”

Despite the call for the specially trained obstetric nurse, many graduates of the recently opened nurse training schools expressed the belief that obstetrical work was “unskilled” (Weld Tallant, 1922), “unattractive,” “below their dignity” (Brown Cooke, 1903), or “uninteresting routine” (Weld Tallant, 1922).2 Textbook authors, however, rationalized that obstetric nurses had to be knowledgeable due to the “grave responsibility” they undertook when managing parturient patients without a doctor present (Brown Cooke, 1903; DeLee, 1916; Fullerton, 1895; Worcester, 1880).

The new professional nurse was called upon to practice based on “knowledge,” rather than “blind obedience” or “common sense” (Worcester, 1880). She was encouraged to “understand” the goals of treatment (Reed, 1917), apply “intelligent observation,” and perform her duties “knowingly” and “thinkingly,” rather than by automation (Plass, 1923). Stowe (1910) noted this was essential when nurses worked with “older graduates in medicine” who may not “. . . appreciate nor desire the elaborate preparations now deemed necessary” for the management of the modern obstetric patient (p. 553). He stated equivocally the professional nurse “. . . is instrumental in raising the standard of obstetric work wherever she goes” (p. 551).

3.1.2. Called to join the fight against the “dangers” of childbirth

Professional maternal-newborn/ obstetric nursing emerged in mid-19th century when childbirth was widely conceptualized as “dangerous” (Brown Cooke, 1903; DeLee, 1916; Fullerton, 1895). Reed (1917) suggested “childbirth is a ‘peril’ equal in severity and seriousness to many of the major operations” (p. 8). Likewise, DeLee (1916) stated that “. . . of every 250 women who become pregnant, at least 1 dies” while many others endure injuries (p. 17). The pregnant woman was believed to be “vulnerable” (Brown Cooke, 1903), and infants “fragile” (Fullerton, 1895) and in need of protection and preventative care to avoid danger (Brown Cooke, 1903; DeLee, 1916; Plass, 1923; Weld Tallant, 1922). The tide, however, was beginning to turn. Plass (1923) suggested that “prophylactic medicine” has done “much good,” and that a properly managed labor was no longer “particularly dangerous” (p.2).3 The professional obstetric nurse was portrayed as essential to decreasing morbidity and mortality; not just by handling emergencies, but also through strict application of aseptic practices (Reed, 1917; Weld Tallant, 1922).

The vital responsibilities of the nurse during this period were described as: gaining the confidence of the patient, education related to the need for medical supervision of childbearing, and maintaining cleanliness and aseptic conditions to prevent harm (Browne Cooke, 1903; DeLee, 1916; Fullerton, 1895; Plass, 1923; Reed, 1917; Weld Tallant, 1922). DeLee (1916) suggested that obstetric standards remained low because “the people are allowed to believe that labor is a natural process and requires no special care (p. 17).” He also suggested the obstetric nurse is akin to a “missionary” spreading the gospel of good obstetrics to the masses.

3.2. 1930′s – 1950′s: maternal-newborn/obstetric nursing moves to the hospital

Nursing textbooks in the 1930′s – 1950′s were increasingly authored by nurses, or nurses collaborating with physicians, but they continue to assert the role of the nurse as the doctor's assistant; one who was under his direct supervision. Up to this time obstetric nurses were encouraged to follow the practices of the particular doctor they assisted (DeLee, 1916). However, as the birth rate climbed and nurses and birthing mothers moved in increasing numbers into the hospital following WWII,4 strict nursing routines were adopted to help standardize care, improve efficiency, and minimize risk of infection (Walzer Leavitt, 1998; Wertz and Wertz, 1989). Walzer Leavitt (1998, 2016) suggests this led to great dissatisfaction from mothers with their nurses due to the impersonal care received.

During this period Wiedenbach (1958) published Family-Centered Maternity Nursing, suggesting an alternative approach to care. This model was directed at maximizing the safety, health, welfare, and preparation of families, while at the same time making childbearing emotionally and intellectually satisfying.5 Wiedenbach (1958) described childbearing as “natural,” thus natural approaches to pain relief and rooming-in were promoted. Although not widely implemented at the time, these principals paved the way for the family-centered model of care widely adopted over the following decades.6

3.2.1. Pregnancy and childbirth necessitate specialized care

By the 1930′s and 1940′s although pregnancy was widely recognized as “natural” (DeLee & Carmon, 1942), and “not a disease” (Van Blarcom, 1934); it was described as a condition requiring great attention and care in order to save lives (DeLee & Carmon, 1942; Van Blarcom, 1934; Woodward, Gardner, Bryant & Overland, 1954; Zabriskie, 1934). During this period 50% of women still delivered at home (DeLee & Carmon, 1942), and although prenatal care had increased, many continued to die of preventable causes (DeLee & Carmon, 1942; Van Blarcom, 1934; Zabriskie, 1934). Zabriskie (1934) notably stressed that morbidity and mortality was highest among non-White races and those living in poverty. Nurse-directed prenatal care, maternal/family education, and use of standardized aseptic principles for all were believed to be essential to optimizing outcomes (DeLee & Carmon, 1942; Van Blarcom, 1934; Zabriskie, 1934; Woodward et al., 1954).7

A primary focus of nursing care through the 1950′s was still “to protect” mothers and newborns from the dangers of childbirth. DeLee & Carmon, (1942) noted that “More women are going into hospitals and the necessity of protecting them from the hazards of cross contamination has been doubled” (p.vii). Van Blarcom (1934), however, speaks hopefully related to “. . . progress in the various branches of medicine and nursing toward greater and more effective safeguards for the maternity patient and her baby” (p.3).

During the 1930′s to 1950′s textbooks also reflected the evolution of a more patient-centered and holistic approach to care. Van Blarcom (1934) stated that good nursing “. . . means care and consideration of the patient as a human being and a determination to nurse her well and happily, no matter what this demands” (p.5). Nurses were described as having a “duty” to their patients (DeLee & Carmon, 1942), encouraged to act professionally and to adopt a spirit of “eager service” (Van Blarcom, 1934), and a “sympathetic” attitude toward women regardless of demographic background (DeLee & Carmon, 1942; Van Blarcom, 1934; Zabriskie, 1934; Woodward et al., 1954). Consideration of the patient's mental state, social context, and nutrition were also now stressed (DeLee & Carmon, 1942; Van Blarcom, 1934; Woodward et al., 1954; Zabriskie, 1934).

3.2.2. The status of obstetrics improves

Through the 1930′s the suggestion persisted in nursing textbooks that obstetric nursing was not considered “desirable” by many professional nurses (Zabriske, 1934). In acknowledgement of this, Van Blarcom (1934) suggested “. . . the maternity nurse should derive deep satisfaction from vicarious motherhood,” and in the giving of herself in service to mothers and infants (p.11). During the same period, however, DeLee & Carmen (1942) suggested things were beginning to change. They asserted “obstetric nursing is steadily gaining the high dignity it deserves” (p. vii).

It has been suggested that it was the significant decrease in maternal/infant morbidity and mortality which began in the 1930′s which increased the status and morale of obstetrics as a specialty (Loudon, 1992). Several medical advancements in addition to better prenatal care, education, and the application of aseptic principles have been credited with this change. These include: the introduction of antibiotics, better knowledge of anesthesia and metabolic disturbances, improved blood transfusion techniques, and improved maternal nutrition (Woodward et al., 1954).8

3.3. 1960′s – 1980′s: knowledge explodes and women find their voice

During the 1960′s–1980′s an explosion of medical knowledge, technology, and social change impacted the practice of maternal-newborn/obstetric nursing (Duncan Jensen et al., 1981; Reeder et al., 1983; Ziegel & Van Blarcom, 1964). This manifested itself in the size and length of maternal-newborn/obstetric textbooks which by the 1980′s had increased to over 1000 pages and 30 or more chapters (see Table 1). Many of these changes occurred in the field of perinatology, and included the advent of continuous fetal and contraction monitoring and new methodologies to manage high-risk pregnancies and infants (Lerch and Bliss, 1978; Reeder et al., 1983; Ziegel & Van Blarcom, 1964).9

Major socio-political changes at this time also greatly impacted women's reproductive rights, allowing for “choice” when before this had been extremely limited.10 Changes in societal attitudes toward childbearing, alterations in family systems, and recognition of alternative lifestyles also impacted the nursing care required during this period (Reeder et al., 1983). Many of these changes were presumably inspired by the so-called “second wave” feminist and women's liberation movements which gained momentum in the 1970′s and gave rise to the associated women's health movement (Dicker, 2016). The tenets of this movement are best encapsulated in the popular publication, Our Bodies Our Selves A Book by and for Women (Boston Women's Health Collective, 1973) whose objective was to conquer women's ignorance about their bodies and reproductive power, help them take control over their own bodies, and learn to advocate for their healthcare needs.

3.3.1. Our understanding of childbearing broadens

By the 1980′s pregnancy and childbearing was conceptualized as more than a normal physiologic event. Duncan Jensen et al. (1981) suggested that due to the wide availability of effective birth control, childbearing had become, “increasingly a voluntary state” (p.10). Further, Reeder et al. (1983) suggested childbearing was presently “a climax of a period of preparation,” instead of “an event to be awaited helplessly” (p. 25). During this period childbearing was also recognized as a developmental opportunity, potential crisis, time of vulnerability to noxious stimuli, and a culturally and societally influenced (Duncan Jensen et al., 1981; Reeder et al., 1983).

Corresponding with the expanded conceptualization of childbearing came the additional understanding this experience should be family-centered. Textbook authors at this time describe the need to address the emotional, physical, and educational needs of not only the childbearing woman but also her family (Bookmiller and Bowen, 1963; Duncan Jensen et al., 1981; Reeder et al., 1983; Ziegel & Van Blarcom, 1964). Authors also suggest families have begun demanding individualized care and choices, among them “natural childbirth” (Bookmiller and Bowen, 1963; Duncan Jensen et al., 1981; Reeder et al., 1983; Ziegel & Van Blarcom, 1964). Leading feminist, Friedan (1970), suggested this new interest in natural childbirth and breastfeeding was inspired by scholars such as Margaret Mead (1949) who glorified the power of women's reproductive role of in her influential research of traditional cultures. The idea of “choice” was a distinct departure from the past when strict adherence to routine practices was believed to be the key to protecting mothers and infants from harm.

3.3.2. The profession matures and nurses become collaborative team members

Early texts from the 1960′s continued to emphasize the nursing functions of teaching and protecting the mother and infant from illness and injury (Bookmiller and Bowen, 1963; Ziegel & Van Blarcom, 1964). However, there are also references to the nurse as a collaborative member of the healthcare team (Ziegel & Van Blarcom, 1964; Duncan Jensen et al., 1981). Duncan Jensen et al. (1981) note that maternity nursing care had evolved over time from “skilled technical care,” to care which meets the psychosocial and physiologic needs of clients, is provided by a variety of practitioners in many settings, and extends from pre-conception to post-delivery family adjustment (p.6).

Evidence of significant growth in nursing science may also be found in textbooks from the 1980′s. Reeder et al. (1983) suggested that nursing care should be based not only on foundational scientific principles, but also fundamental “concepts” needed to deliver high quality care. Most significantly, during the 1980′s the “nursing process” was introduced (Duncan Jensen et al., 1981; Reeder et al., 1983). This represented a dramatic shift in the role of the nurse from someone who acts as the doctors’ representative, to one who develops and carries out an individualized plan of care.

Textbooks during this period also explicitly described new specialties in maternity nursing including perinatology (Reeder et al., 1983). Alternative, advanced nursing roles were also highlighted including: nurse midwife, obstetrical-gynecological nurse practitioner, women's healthcare specialist, maternity clinical specialist, and nurse researcher (Duncan Jensen et al., 1981; Reeder et al., 1983).11The opportunities for specialty and advanced practice which arose during this period challenged traditional definitions of maternal-newborn/obstetric nursing, and suggested the possibility of further collaborations yet to come.

3.3.3. Some families remain more vulnerable than others

During this period textbook authors credited the strong trend toward hospital births, an increase in prenatal care, and more successful medical management of toxemia, infection, and hemorrhage as responsible for a further decrease in mortality (Bookmiller and Bowen, 1963; Reeder et al., 1983; Ziegel & Van Blarcom, 1964). Despite progress, these conditions were still the leading causes of death, particularly among underserved nonwhite women and those in lower socioeconomic groups (Bookmiller and Bowen, 1963; Reeder et al., 1983; Ziegel & Van Blarcom, 1964). Ziegel & Van Blarcom (1964) suggested “Services must be spread to the people who do not have excellent care, and the depth of service increased for those who are receiving good care” (p. 726–727). Like their predecessors, textbook authors concur that comprehensive care for all women was needed to further decrease mortality (Bookmiller and Bowen, 1963; Reeder et al., 1983; Ziegel & Van Blarcom, 1964).

3.4. 1990′s to the present: charting the future

In the last several decades changes in the healthcare system, society, and family expectations have further altered how pregnancy and childbearing is conceptualized, and maternal-newborn/ obstetric nursing is practiced. These changes include: increased use of technology, single room LDRP care, cost containment efforts, decreased length of stay, increased community-based care, more high risk patients, an enlarging multi-cultural population, and consumer demand for choices including family-centered care and complementary medicine (Davidson, London, and Wieland Ladewig, 2016; Dickanson, Silverman, and Kaplan, 1998; Lowdermilk and Perry, 2007; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010). An associated shift in nursing care has occurred toward an emphasis on teaching, counseling, and supportive functions directed at promoting wellness, self-care, independence, and family adjustment (Davidson et al., 2016; Dickanson et al., 1998; Lowdermilk and Perry, 2007; Smith Murray and Slone McKinney, 2010).

3.4.1. Childbearing becomes a family-centered, developmental transition

Textbooks since the 1990′s have consistently asserted the modern conceptualization that pregnancy and childbearing is a normal, family event that should be family-centered (Davidson et al., 2016; Dickanson et al., 1998; Lowdermilk and Perry, 2007; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010). Further, Nichols and Zwelling (1997) suggest that childbearing is an opportunity for a woman to find inner strength and increase self-esteem, while Smith Murray and Slone McKinney (2010) suggest childbirth holds the potential for both growth and problems. There is consensus that pregnancy and childbearing is a “developmental” period (Davidson et al., 2016; Dickanson et al., 1998) or “major life transition” (Nichols and Zwelling, 1997), which challenges individual and family coping skills and requires nursing support.

While textbook authors continue to assert that maternity nursing should be based upon underlying scientific principles, they also emphasize the important roles of both theory and research (Davidson et al., 2016; Dickanson et al., 1998; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010). Authors note theory provides both a broader framework for practice and increases understanding (Davidson et al., 2016; Nichols and Zwelling, 1997). Likewise, “evidence-based practice” is now universally lauded as the key to maintaining a current, scientific basis for nursing, and the best means to investigate clinical issues (Davidson et al., 2016; Lowdermilk and Perry, 2007; Smith Murray and Slone McKinney, 2010).

3.4.2. The complexity of care favors increased responsibility, specialization, and accountability

It is clear that technological advances, societal changes, and changes in the healthcare system have increased the responsibilities of maternal-newborn/ obstetric nurses. Today's nurses are called upon to use “critical thinking” when addressing the needs of their patients (Davidson et al., 2016; Lowdermilk and Perry, 2007; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010). This is not, however, unlike earlier suggestions that professional nurses act based on “knowledge” rather than “blind obedience” (Worcester, 1880); or “knowingly” and “thinkingly,” rather than by automation (Plass, 1923). The increasing complexity of care has also led to continued opportunities for nurses to collaborate, specialize, and assume managerial or advanced practice roles (Davidson et al., 2016; Dickanson et al., 1998; Lowdermilk and Perry, 2007; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010).

In recent decades the expanded maternal-newborn/obstetric nurse's role has come with a greater demand for accountability (Davidson et al., 2016; Dickanson et al., 1998; Lowdermilk and Perry, 2007; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010). Dickanson et al. (1998) assert the legal obligation of the nurse has “assumed a greater importance than in earlier decades due to the fact that the public is generally more knowledgeable, use of technology is more sophisticated, and care is increasingly specialized, requiring knowledge” (p. 8). Thus, the professional obligation of nurses to practice according to a recognized standard of care has become mandatory during this age of increasing oversight.12

3.4.3. Disparities and preventable deaths persist

Although infant mortality has continued to decrease steadily over the last several decades, the decrease has been greatest among Caucasian infants (Davidson et al., 2016; Dickanson et al., 1998; Lowdermilk and Perry, 2007; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010). Davidson et al. (2016) document that the U.S. infant mortality rate has dropped to 27th among industrialized countries, a rank attributed to a disproportionally high number of preterm births.

Maternal mortality has also generally continued to decline worldwide, but it has fluctuated and risen in the U.S. since the 1980′s, and the risk of death remains higher among African-American and other minorities than Caucasian women (Davidson et al., 2016; Dickanson et al., 1998; Lowdermilk and Perry, 2007; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010). In this climate the call for comprehensive care for all pregnant women remains as strong today as when it began decades ago (Davidson et al., 2016; Dickanson et al., 1998; Lowdermilk and Perry, 2007; Nichols and Zwelling, 1997; Smith Murray and Slone McKinney, 2010). This sobering reality verifies that although childbearing is no longer considered “dangerous,” protection of all maternal and infants from harm, particularly the most vulnerable, remains a significant concern.

4. Discussion

As revealed in the sub-sections of the nursing textbooks analyzed there has been considerable change over time in professional maternal-newborn/obstetric nursing, although certain key components of the role have remained the same. Despite steps taken to address the rigor in the current analysis, the findings are limited by the textbooks available, the amount of data extracted from each, the four time periods compared, and the fact that only one researcher coded the data. Future analysis of similar data sources will serve to either confirm, expand upon, or contradict the current interpretation.

Over time dramatic changes in medical science, technology, society, and the healthcare system have shaped the evolution of professional maternal-newborn nursing. Concurrently a dramatic change has occurred in our conceptual understanding of pregnancy/childbearing and the relative vulnerability of mothers and infants. The professional maternal-newborn/obstetric nurses’ commitment to protect mothers and infants from harm, however, has not diminished over time. In fact prevention, asepsis, and attention to safety are still as relevant today as in the past.

The need for nurses to counsel/teach their patients has also never diminished. Rather, it has taken on an even more vital role as today's nurses strive to promote self-efficacy, independence, self-care, and successful transition to increasingly diverse families. Also, supporting our patients is now more meaningful than ever in the complex, technologically-heavy healthcare environment, where patients may feel alienated and powerless. However, the fact that while some things have changed, many have remained the same, suggests that if maternal-newborn/obstetric nurses want to have a real impact on the type of care provided to childbearing families in the future, we need to actively support healthcare reform.

Regardless of progress that has been made in safely managing routine deliveries, recurring themes in the textbooks analyzed were: (1) recognition that high quality healthcare is not available to all childbearing families (in particular minorities and low income), and (2) preventable maternal/infant morbidity and mortality remains too high. Based on the analysis completed this has been a recognized problem for nearly a century. If maternal-newborn/obstetric nurses today are to remain true to their long history of protecting, counseling/teaching and support of childbearing families, they must consider what role they wish to play in addressing these and other key issues.

Another challenge underscored by the present analysis is that although nursing textbooks since the 1930′s have emphasized the belief that pregnancy and childbearing are “natural” and “normal,” in the U.S. a strong pattern of medical management of birth still predominates. The cesarean section rate remains high at 31.7% in 2019 (Hamilton, Martin, & Osterman, 2020), approximately 83% of infants are delivered by physicians, and only 10% are delivered by midwives (Declercq et al., 2013). Mothers also report high levels of intervention in vaginal births; with 67% indicating their provider attempted to induce their labor, 83% utilizing one or more types of pain relief (62% an epidural or spinal), and frequent use of vaginal exams, intravenous fluid, urinary catheters, Pitocin, amniotomy, episiotomy, and continuous fetal/contraction monitoring (Declercq et al., 2013).

This suggests that although second wave feminism and the women's liberation movement may have inspired women to seek more control over their childbearing experience, the primary force guiding the childbearing experience in the U.S. is still the physician (Declercq et al., 2013). This situation continues despite mounting evidence which supports the efficacy of low intervention childbirth practices such as those provided by nurse midwives (Enkin et al., 2000; Romano & Lothian, 2008). Professional maternal-newborn/ obstetric nurses have an opportunity to join the call to minimize interference with the natural birth process which has been widely endorsed internationally (International Childbirth Initiative, 2018). This would, however, require altering the perspective of many obstetric nurses who were trained in a technologically intense birth environment. Research suggests for a more natural approach to labor and delivery to work, support needs to come not only from the organizational level but from bedside nurses (Everly, 2012).

In the last two decades the U.S. Institute of Medicine (IOM, 2000, 2001, 2010) and the WHO (2010) have suggested that interprofessional collaboration, including the participation of nurses as full partners, is key to successfully re-shaping the future of healthcare. In regard to childbearing, research supports the efficacy of interprofessional collaboration in the clinical setting. Lundsberg et al. (2019) found that hospitals utilizing midwife-led or physician-midwife collaborative birth management approaches were 7 times more likely to use low intervention practices that those managed solely by physicians. In addition, Colter Smith et al. (2019) found interprofessional healthcare care teams including midwives were associated with lower rates of labor induction and cesarean section.

Routine labor induction, operative birth, and other unnecessary interference with natural birth processes are known to be associated with increased risk of complications rather than benefits (Enkin et al., 2000). The fact that low-tech midwifery care is safe and also more cost effective than that provided by a physician, strongly suggests that increased use of nurse midwifery services could not only shift the management of pregnant/childbearing women in the U.S. toward the “support of normalcy” (Powell Kennedy and Shannon, 2003), but also increase access to care to underserved childbearing populations and decrease maternal/ newborn morbidity and mortality.

The Institute of Medicine (2010) recommends that in order to truly participate in redesigning healthcare in the U.S. the nursing workforce needs to be more highly educated, used more effectively across settings, and serve in leadership positions at all levels. According to the AACN (2019) there is currently greater than ever support for BSN entry level into practice from federal agencies, key nursing organizations, and nursing management.13 Maternal-newborn/ obstetric nurses might seriously consider supporting this educational initiative. Such a movement could open up further opportunities for nurses, increase respect from other members of the healthcare team, and give our opinions more weight in interprofessional discussions.

5. Conclusions

Professional obstetric nursing emerged in the mid-19th century due to the physician's need for an assistant to help with the medical management of childbirth. Since its origins, however, the profession has matured and nursing's allegiance is now clearly to patients and society (ANA, 2010). Today's nurses have an opportunity to play a key role in advocating for systematic change in the present healthcare system which will allow for less interference in the natural birth process, maximize patient outcomes, decrease inequities, and make comprehensive care for all mothers and infants a national priority. The time has come for nurses to join the interprofessional team as full partners, working at multiple levels, to shape the future of healthcare for childbearing families.