The year 2020 marks one of those global tipping points – time divided into pre-COVID and the promise of after COVID, as well as open rallying cries to topple white patriarchal supremacy. Serendipitously, it also marks the Year of the Nurse and the Midwife, per the World Health Organization. We were excited: as two practicing, politically radical midwives of color, this was going to be our year when the world would celebrate, honor, and uplift our work in meeting the essential needs of people all over the world. And then in May, following the death of George Floyd, the fire of civil unrest and collective action and protest around racial injustices was lit. It was the perfect reckoning point for us to look “Beyond Florence.” We want to share with you the story of American midwifery and disrupt the narratives of some of our “statues,” long-standing symbols of what is now an extremely white female profession.
US exceptionalism in maternity care is marked by the lack of midwives as primary providers. Out of 100 births, only 10 to 12 will be attended by a midwife – and 9 out of 10 of these midwives are white.1 Yet globally, most childbearing women are attended to by midwives, only turning to an obstetrician if serious complications arise. According to WHO and The Lancet, midwives could help avert roughly two-thirds of all maternal and newborn deaths, while providing 87% of all essential sexual, reproductive, and maternal health services.2 Midwifery is one of the most ancient of traditions and professions in the world, with roots that can be traced back to the healing traditions of Babylonia, Egypt, Ancient Greece, Vedic India, and the Aztecs. How has this essential role been so obliterated with barely a peep from feminists claiming reproductive liberation and rejecting male domination, pink pussy hats and all? How did we lose our way in this long-standing battle to keep the patriarchy out of our pregnant uteruses? And why is American midwifery so white?
For most of early American history, midwives attended all births, many learning the tradition as apprentices or inheriting a gift for healing and earth-based remedies. For enslaved African women, the traditions of midwifery traveled with them, as birth was considered the domain and realm of women midwives as community healers. In fact, obstetrics was not taught in most medical schools. However, as the business of medicine grew in the 1800s, physicians began to stake a claim. Childbirth was lucrative – a chance to make money while experimenting with emerging technologies like forceps, episiotomies, and surgery.
Coupled with the creeping privatization of American health was the near obliteration of birthing at home. Part of this was the growing narrative that birth was risky, needing constant vigilance for medical interventions. Bringing birth into the hospital was business strategy 101: bring the customer to you, manage more than one labor at time, centralize care, and create a medical birth monopoly completely controlled by male obstetricians.
In the early 1900s, close to 50% of births were attended by midwives, with a much higher percentage of Black births attended by Black midwives. These midwives served their communities diligently, providing care for generations of families – and white plantation owners too. The campaign to rid communities of these Black healers was mired in racist tropes (uneducated, dirty, poor, feeble) and threats of being prosecuted for “practicing without a license.” Meanwhile, a report on medical education in America demonstrated that obstetricians were among the most poorly trained physicians, contributing to maternal and infant mortality. But the professionalizing project of medicine in the US resulted in rigid laws, regulations, and procedures and concurrently the overmedicalization of birth. In order to address the “midwife problem,” public health nurses were dispatched by order of public health directors – male physicians – to regulate, limit, and surveil these Black “granny” midwives.3
The passage of the 19th Amendment was a tipping point, instantly doubling the voting population. In an effort to appease these new voters, Congress developed the Promotion of the Welfare and Hygiene of Maternity and Infancy Act, more commonly known as the Sheppard-Towner Act (1921). Senator Morris Sheppard, the erstwhile father of the Prohibition Act, and Representative Horace Mann Towner proposed and passed legislation that would address the terrible infant mortality by developing a federally-funded public health workforce. They adopted the narrative set by obstetricians that it was midwives, mostly Black, with limited education (ignorant), and poor hygiene (dirty) who were culpable for the high death rate. The twin arms of white supremacy – anti-Black racism and xenophobia – convinced Black women and northern immigrants that midwives were to be bypassed and that a responsible mother would seek out the care of white male physicians, the new arbiters of medical science and experts on the disease of pregnancy.
One direct result of the Sheppard-Towner Act was the creation of a white public health nurse workforce that became the genesis of the modern nurse-midwife. They provided care that was neither culturally congruent nor women-centered, while supervising Black and immigrant midwives on the proper techniques of care. These same white nurse-midwives also became the cudgel that would control, suppress, and eliminate the Black, Indigenous, and immigrant midwifery workforce from 1920 to 1945, both as teachers and as state agents of legal and regulatory enforcement. By this time, only 15% of births were attended by midwives, down 35% from only decades earlier.
That brings us to the “Florence” of nurse-midwifery in the US, Mary Breckinridge. A child of a large, prominent, socially elite, and wealthy southern segregationist family, and granddaughter of a former vice president of the United States, Breckinridge started a demonstration project in 1925 to prove that the midwifery model of care could increase child survival in rural Appalachia. Also a white supremacist and eugenicist, Breckinridge believed that the people of Appalachia were “pure” Americans, descended from Anglo-Saxons, of superior breeding stock needed to grow a feeder population.4 In 1940, Breckinridge started the Frontier Nursing Service (FNS), an education program that didn’t admit a single Black nurse until her death in 1965.5 Even Black women in the service area of FNS did not receive care from the all-white workforce of nurse-midwives on horseback. FNS nurse-midwives denounced the work of the local granny midwives as a way to uplift their own professional status, while systematically replacing them as the region’s birth attendants. The school lives on and is one of the largest nurse-midwifery schools in the country.
In New York, the Lobenstein Clinic and Maternity Center Association (MCA) launched the first US nurse-midwifery education program in 1932. Founded by a group of influential white women, MCA trained hundreds of nurses to become nurse-midwives to work in hospital maternity services to meet the demand of the baby boom. In its first twenty years, only eight Black nurses received midwifery training. Black midwives in the southern United States were publicly characterized as “unsanitary and superstitious,” in contrast to the well-trained midwives of Bellevue hospital, who were of European descent.6 For twenty years, midwifery remained in the control of nursing programs, a reality that continues today.
With the growth of the second wave of white feminism and women’s liberation in the early 1970s, newfound interest in midwifery emerged, with sexual and reproductive freedom as part of its ethos. Though hyperfocused on abortion and contraception, this new movement of self-taught mostly white women, created a renewed image of birth, intentionally distancing themselves from the medical establishment that also shunned nursing. There was little acknowledgment of the ancient, expert, and holistic practices of Black, Indigenous, and immigrant healers that birthed nearly twenty generations of Americans of all ethnicities – with midwives like Onnie Lee Logan, Margaret Charles Smith, Mary Francis Hill Coley, and the few Black nurses who overcame the obstacles white supremacy put in place to become nurse-midwives like Maude Callen.7
These years of systemic exclusion resulted in the midwifery workforce and midwifery education of today. Of the thirty-nine graduate programs that train certified midwives and nurse-midwives, only two have Black program directors – one permanent and one interim. In 2020, Commonsense Childbirth School of Midwifery founded by Jennie Joseph, a British-trained midwife, was the first certified professional midwife (CPM) education program in the US to be led by a Black woman.
So the question in a country whose foundations remain rooted in white supremacy is whether midwives are ready for a reckoning. Can midwifery uproot themselves from its ties to misogyny and white supremacy in a workforce that currently identifies as 90% white, in a population that has increased from only 150 in 1955 to 12,000 today? If midwifery is to thrive into another century in the United States – in the midst of a deeply racialized maternal health crisis, where Black women are three to four times more likely to die in a childbearing complication – then we need to start looking for a way to invest and support the growth of Black, Indigenous, and immigrant midwives of color to reclaim the legacy of midwifery that existed well before Mary and Florence.8
- According to the American Midwifery Certification Board, as of 2019, close to 90% of all midwives in the US identify as white. Return to text.
- M. J. Renfrew, A. McFadden, M. H. Bastos, J. Campbell, A. A. Channon, N. F. Cheung, and E. R. Declercq, “Midwifery and Quality Care: Findings from a New Evidence-Informed Framework for Maternal and Newborn Care,” The Lancet 384 (2014): 1129–1145. Return to text.
- J. M. Luke, Delivered by Midwives: African American Midwifery in the Twentieth Century South (University Press of Mississippi, 2018).; K. Dawley, “The Campaign to Eliminate the Midwife,” American Journal of Nursing 100, no. 10 (2000): 50–56. Return to text.
- D. A. Johnson, “‘A Cage of Ovulating Females’: Mary Breckinridge and the Politics of Contraception in Rural Appalachia,” (MA thesis, Marshall University, 2010). Return to text.
- Johnson, “A Cage of Ovulating Females.” Return to text.
- S. Morrison and E. Fee. “Nothing to Work with But Cleanliness: The Training of African American Traditional Midwives in the South.” American Journal of Public Health 100, no. 2 (2010): 238–239. Return to text.
- O. L. Logan and K. Clarke, Motherwit: An Alabama Midwife’s Story (E. P. Dutton, 1989). Return to text.
- E. E. Petersen, N. L. Davis, D. Goodman, S. Cox, C. Syverson, and K. Seed, “Racial/Ethnic Disparities in Pregnancy-Related Deaths—United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (2019): 762–765. Return to text.
This article is fascinating, illuminating and riveting. I’ve learned so much. Healthcare needs to be decolonised as do all the health professions. Thank you for sharing your knowledge and understanding.