BACKGROUND. The use of midwives is a natural solution to the problem of improving access to skilled perinatal services while lowering costs. The number of midwife-attended births has grown from 0.9% of all births in 1975 to 3.4% of all births in 1988. The purpose of the study was to determine how mothers served by midwives and the settings in which they are served have changed in that period. METHODS. The analysis is based on birth certificate data from 1975 to 1988 from the Natality, Marriage and Divorce Statistics Branch of the National Center for Health Statistics, Centers for Disease Control. RESULTS. Almost all of the growth (93.2%) in midwife-attended births from 1975 to 1988 was in hospitals; 87.3% of all births attended by midwives occurred in hospitals. Pronounced differences exist between mothers served by midwives in and outside of hospitals, and there are strong regional patterns in midwife attendance at birth. CONCLUSIONS. Given the positive outcomes associated with midwifery practice, further research into the content of midwifery care is recommended.