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Present at the Creation
How a School of Nursing professor helped transform midwifery from an illegal backwoods tradition into a respected medical profession.
September/October 2004
by Cathy Shufro
Cathy Shufro, a freelance writer based in New Haven, writes frequently about medical issues.
If a woman falls on a pitchfork, and drives the handle through her perineum, we call that pathologic—abnormal, but if a large baby is driven through the pelvic floor, we say that it is natural, and therefore normal … I have often wondered whether Nature did not deliberately intend women to be used up in the process of reproduction, in a manner analogous to that of the salmon, which dies after spawning.
—Joseph B. DeLee, “The Prophylactic Forceps Operations,” American Journal of Obstetrics and Gynecology, 1920
In 1960, when Helen Varney Burst began studying nursing at the University of Kansas, the accepted medical approach to childbirth was still governed by the recommendations Joseph DeLee had made in his influential article 40 years before. When a woman neared the end of labor, her physician would inject anesthetic into her lower spine, immobilizing her from the waist down. He would strap her legs into stirrups, tie down her hands, cut an episiotomy to enlarge her vaginal opening, and insert forceps to grasp the baby’s head as it emerged. Afterward, the doctor would stitch up the incision. All this was considered “the Cadillac of care.”
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“She was the talk of the hospital. They hadn’t seen a natural birth in so long.” |
But events departed from this script when Varney Burst '63MSN witnessed her first labor. One spring evening during her junior year, hearing that the pregnant patient she'd been assigned to follow was in labor, she rushed to the hospital. She sat all night with the young woman in the labor room, guiding her now and then in deep breathing to ease pain. Beyond this, Varney Burst had no idea what she was doing: she had never seen labor or a birth, and she and her classmates hadn’t yet studied “intrapartum.” She remembers sitting with the woman through a peaceful night, taking occasional catnaps. And then the mood in the room shifted.
“Something is different,” recalls Varney Burst, sitting in the conference room at the Yale School of Nursing, where she has taught midwifery since 1979. “She says she has to push. The unspoken question in my mind is: does this mean anything?” Varney Burst laughs as she remembers this, blue eyes wide behind her owlish glasses, dangling earrings swaying beneath silver hair cut in a pageboy. She tells how she hurried down the hallway to find her nursing instructor. By the time they returned, the baby’s head was already crowning; it was too late to anesthetize the mother for a forceps delivery.
“She was the talk of the hospital,” says Varney Burst. “She'd had a natural birth. They hadn’t seen one in so long.”
Even today, the divide persists between the interventionist approach DeLee advocated and a more benign view of natural birth. To a large extent, standard obstetrics incorporates technological advances developed for high-risk pregnancies and births into the routine care of pregnant women. Electronic fetal monitoring, for instance, may reassure a woman in labor that every precaution is being taken. But it has also been implicated as a key factor in increasing the rate of surgical births in the United States to one in four—ten percentage points higher than the rate sanctioned by the World Health Organization.
Midwifery is grounded in the perspective that most women—given physical and psychological support by a trained midwife and accompanied by loved ones—will give birth safely with few, if any, interventions. Midwives screen their patients carefully, watch for complications, and rely on obstetricians in cases requiring intervention. But they spend much of their time educating patients and tend to see their role as collaborative rather than authoritative.
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41 years ago, midwifery was legal only in New Mexico, Kentucky, Baltimore, and New York City. |
When Varney Burst began her midwifery studies, nurse-midwives worked only on the margins. They were entrusted with the care of inner-city women too poor to hire a doctor and rural women who weren’t prosperous enough, or white enough, to enter a hospital. Nurse-midwifery was legal in only two states and two cities: New Mexico and Kentucky; Baltimore and New York City.
But during Varney Burst’s 41-year career, nurse-midwifery has come into its own. The profession has developed national standards for education, accreditation, and certification and produced a strong foundation of clinical research. More American women are choosing midwives. In 1975, only 0.6 percent of women giving birth in the United States used midwives. By 2002, 10 percent of women giving birth vaginally chose midwives for their care. The values of midwifery and the women’s health care movement have also influenced obstetricians, who now welcome fathers at births, advocate childbirth classes, and no longer routinely use forceps.
Varney Burst has played an instrumental role in the emergence of midwifery. She wrote the first and most widely used textbook of American midwifery. She helped create a curriculum that transformed midwifery education nationwide. She has twice served as president of the American College of Nurse-Midwives. When she retired from her Yale professorship of nursing this June at the age of 64, Yale announced another first: the nursing school is raising money to fund the Helen Varney Chair in Midwifery, the first university-endowed midwifery professorship in the nation. Says Donna Diers '64MSN, former dean of the School of Nursing, “Helen has literally reinvented the profession.”
When Varney Burst witnessed that first uncomplicated labor in Kansas, she had no idea midwifery would be her life’s work. She didn’t even know the meaning of the word. Her ambition was to finish nursing school, study for a master’s degree in nursing, and join the faculty of a nursing school. She chose Yale for her master’s so she could study with Ernestine Wiedenbach, author of her favorite textbook, Family-Centered Maternity Nursing. In an era when women were often left completely alone during labor, Wiedenbach believed nurses should stay with them, providing reassurance and physical care, and she advocated keeping newborns with their mothers rather than in nurseries down the hall.
Going to Yale meant crossing the Mississippi for the first time and moving half a continent away from her parents, Theodore Roosevelt Varney, who owned a college bookstore, and Helene Hahn Varney, a piano teacher and the daughter of a Kansas wheat farmer. When Varney Burst flew east for her interview, she was disappointed by the drab New York skyline. She mentioned this to a fellow bus passenger. “He thought I was the original hayseed,” she says. “We were in Newark.”
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“The uterus is an amazing organ.” |
Yale offered a midwifery elective for master’s nursing students (although, for legal reasons, the training for the birth section took place at Kings County Hospital in Brooklyn). Varney Burst signed up, thinking the extra instruction would help her stay one step ahead of her future nursing students. That first summer, helping women give birth, she felt “a combination of reverence and exhilaration. It is very awe-inspiring to be present at a birth, to be present at a time when a baby is born, born into your own hands.”
She learned the midwife’s “bag of tricks”: techniques for helping to ease pain through pressure, showers, ice packs, breathing; for finding good positions for pushing out a baby; for supporting the perineum during birth to keep it from tearing; even for getting a balky labor started without drugs.
She also cemented her own philosophy of midwifery. “The uterus is an amazing organ,” she says, “the only organ in the body that can stretch like that and then go back into its original size and shape. All these processes involved in reproduction are truly to be held in reverence.”
Throughout her career, this perspective on natural birth would often bring her into conflict with mainstream obstetricians. Midwives, says Donna Diers, have had “to be very sure of who they were, because they’ve fended off all kinds of attacks from organized obstetrics and unenlightened media who characterize them as ‘nuts and berries.’” Varney Burst accepts this role. “In general, obstetricians view birth as inherently complicated and potentially dangerous until proven otherwise,” she says, “and midwives view birth as inherently normal until proven otherwise. Midwives are guardians of the normal.”
It was after she graduated from Yale, while she was teaching undergraduate obstetrical nursing at the University of Wisconsin-Madison, that Varney Burst’s career plans shifted from nursing to midwifery. But what set her on course as a pioneer of the teaching and professionalization of midwifery wasn’t birth, but two deaths. One was her husband's. She had met Howard Williams in New Haven, and they married and moved to Wisconsin after she graduated. (The name Burst comes from a brief marriage in 1971 that ended in divorce.) One afternoon five years later, Varney Burst got a call at work. Her husband had called a doctor for help and died en route to the hospital. His death was never explained. He was 31 years old.
Varney Burst stayed in Wisconsin for another year. “I believe in confronting grief where it was,” she says. But she wanted to get back to midwifery, and when the year was over she returned to Kings County Hospital for a midwifery internship.
The other death took place in Mississippi. A nurse named Marie Meglen had taken a woman and her desperately ill baby to a hospital. The hospital turned them away because the mother and child were black. Meglen tried taking the baby in herself and was refused. The baby died in her arms.
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When a white midwife and a black midwife decided to room together, they were told they would be shot. |
Galvanized, Meglen enrolled in midwifery school at Columbia University. She and Varney Burst met at Kings County. It was 1969, two years after Robert F. Kennedy had exhorted the nation to aid the impoverished children of the Mississippi Delta. In response, Congress had funded the County Health Improvement Project to educate nurse-midwives in Mississippi and provide care in five counties. Meglen was the first nurse-midwife hired. She recruited Varney Burst to join the group.
At first, Varney Burst didn’t want to go. “All I could think of was the heat,” she says. But on May 3, 1969, the second anniversary of her husband’s death, she drove north to New Haven for what she thought would be a nostalgic trip recalling their courtship. Instead, seeing the places she had known with her husband “was the worst thing I could do. I was devastated. I’m driving down the Merritt Parkway. I’m in tears. In a prayer to the Lord, I ask, ‘What am I supposed to do?’ I just knew the answer. ‘You are to go to Mississippi.’ I said, ‘I don’t want to go to Mississippi.’ The answer was: ‘You are going to Mississippi.’”
Varney Burst and five colleagues arrived in Mississippi that summer. When a white midwife and a black midwife decided to room together, they were told they would be shot. “We had every reason to believe it,” says Varney Burst.
The midwives ruled out home births because few houses had screens or running water. The County Health Improvement Project would pay for hospital services for patients—and the nurse-midwives insisted that their patients, all of them African American, would enter by the front door.
One of their goals was to cut the very high infant mortality rate. Babies were dying from diarrhea, pneumonia, and fireplace burns. “These were preventable deaths,” says Varney Burst. But the mothers had no experience of regular health care and often sought help only when a child was already desperately ill or critically injured. The midwives hoped that if they earned their patients' trust and provided access to good care, mothers would seek help sooner. The white staff in the local clinics, Varney Burst says, would shout at patients from across the waiting room: “Willie Mae, have you peed yet?” The midwives, instead, would “go up, chart in hand, and say, 'Mrs. So-and-So, would you please come with me for your visit?' If they trusted us, they would let us know when anything was going wrong with these babies. And that’s exactly what happened. That’s how we cut the infant mortality rate in half.”
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“It was very different from the usual 'I dare you to prove you can be a nurse' approach.” |
Varney Burst also taught at the University of Mississippi Medical Center in Jackson. Her students' previous training varied from three-year nursing diplomas to graduate degrees, so she and two others created a curriculum that allowed students to focus on new material while quickly reviewing what was familiar. This “mastery learning” approach would become standard in midwifery education nationwide. “We were treated as colleagues who were in a growing mode,” remembers Texas nurse-midwife Nancy Jo Reedy, one of 11 members of the Class of '73. “It was very different from the usual 'I dare you to prove you can be a nurse' approach.”
After five years in Mississippi, Varney Burst settled happily in Charleston, South Carolina, where she worked on her self-imposed task of writing an American midwifery textbook. She also directed the nurse-midwifery program at the Medical University of South Carolina for about a year, until a conflict with the obstetrics department chair tested her principles.
The university’s nurse-midwifery program provided prenatal care at clinics in and around Charleston. But because the obstetrics chair opposed home births, the nurse-midwives could not attend the labor of any patient who chose to have her baby at home.
One day a Charleston woman who had given birth at home came to the hospital with a serious tear. In response, the obstetrics chair decreed that no nurse-midwife could provide prenatal care for a woman planning a home birth. “I just found this intolerable,” says Varney Burst. “I said, 'I can’t do this. I will have to resign.' And I think he smiled.”
Varney Burst went “home to Yale” in the summer of 1979 to chair the nurse-midwifery program at the School of Nursing. There she taught in the clinic and in the classroom. Her textbook was published in 1980 as Nurse-Midwifery. By the third edition, the name was Varney’s Midwifery. “She’s touched virtually every midwife with her writing,” says Jan Kriebs '83MSN. “It is the American textbook in midwifery.” Kriebs was a co-author on the award-winning fourth edition, published in 2004. With new chapters addressing every aspect of women’s health, from adolescence to old age, it weighs about seven pounds—a nice size for a newborn.
At Yale, too, Varney Burst ran into controversy, when she helped found a childbirth center in the mid-1980s. She remembers a prominent local pediatrician “pounding on my desk about how I am going to kill babies.” The center closed after only a year and a half. Other local midwives and a doctor point out that the center struggled partly because of a malpractice insurance crisis, and partly because some doctors and nurse-midwives weren’t eager to be on call for births at more than one location. But Varney Burst believes that the chair of the obstetrics department encouraged obstetricians to stay away from the center. (Then-chair Dr. Frederick Naftolin, still at Yale, denies this claim, but he adds that the university department of obstetrics “felt unanimously that in the contemporary United States it was inappropriate to have out-of-hospital birthing centers in urban areas.”) “It became very obvious that my life pattern was that of Sisyphus,” Varney Burst says.
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By the late 1980s, nurse-midwifery was legal in all 50 states. |
She was more successful as an advocate—giving speeches around the country, writing articles, and working with physicians' groups to help legitimize nurse-midwifery. By the late 1980s, nurse-midwifery was legal in all 50 states and its safety was clearly established. A 1998 study found that the rates of infant death, neonatal mortality, and low birth weight were significantly lower for babies born with midwives than for those born with doctors—even controlling for medical and socioeconomic risk factors.
Yale’s Donna Diers adds that the values of midwifery subtly changed the School of Nursing. Mainstream nursing schools are so harsh on novices that nurses often joke about “eating their young.” But nurse-midwives—and the School of Nursing has trained 500 since starting its midwifery program in 1956—have a different approach: “not to bring one’s own intentions and wishes to bear upon others. They do that with each other and with anyone who works with them. It’s possible to name many things Helen did, and did very well. What is more important is her very presence. She makes us behave better.”
A few days before her official retirement date, Varney Burst is rather desperately trying to pack up the books, journals, notebooks, and manuscripts she has crammed into her small office at the nursing school. She is sorting the boxes: boxes for her home in New Haven, boxes for the house in Maine that she shares with nurse-midwife and lawyer Margaret-Ann Corbett. She will use her retirement to write a history of nurse-midwifery in the United States.
Varney Burst never gave birth herself. “I’ve always missed having that experience,” she says. “But what it means is that I never superimpose my experience on somebody else's. I simply learn from each woman who has had this magnificent experience.” What does grieve her is the aftermath of fractures she suffered in her right arm and elbow in falls ten years ago. The injuries left her right hand too inflexible to do pelvic exams, and she endured two years of daily physical therapy in an effort to regain her muscle control. But one day, during a patient visit, “I realized I really couldn’t do it.” She managed to get out into the hallway, but then, “to my horror, I totally fell apart. There’s nothing you can do in midwifery that doesn’t require a pelvic exam.” Her years of attending births and teaching clinical skills to students, her two greatest joys, ended that day.
“I think that’s been more painful to me than anything else,” she says, rolling up her sleeve to show the long scar running down her arm. “At one time I was, truly—well, I was the best. I should say one of the best. I was good. ”
Out in the world, more than a thousand people who were born into her hands are living their lives. And more women are choosing midwifery when they give birth. “I was the 401st member of the American College of Nurse-Midwives in 1963,” says Varney Burst. “And we’re over 7,000 members now. It may go in cycles, but we’ll do nothing but increase. We’re not about to go away.  |
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