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Delivered by Midwives: African American Midwifery in the Twentieth-Century South
Winner of the 2019 American Association for the History of Nursing Lavinia L. Dock Award for Exemplary Historical Research and Writing in a Book
“Catchin’ babies” was merely one aspect of the broad role of African American midwives in the twentieth-century South. Yet, little has been written about the type of care they provided or how midwifery and maternity care evolved under the increasing presence of local and federal health care structures.
Using evidence from nursing, medical, and public health journals of the era; primary sources from state and county departments of health; and personal accounts from varied practitioners, Delivered by African American Midwifery in the Twentieth-Century South provides a new perspective on the childbirth experience of African American women and their maternity care providers. Author Jenny M. Luke moves beyond the usual racial dichotomies to expose a more complex shift in childbirth culture, revealing the changing expectations and agency of African American women in their rejection of a two-tier maternity care system and their demands to be part of an inclusive, desegregated society.
Moreover, Luke illuminates valuable aspects of a maternity care model previously discarded in the name of progress. High maternal and infant mortality rates led to the passage of the Sheppard-Towner Maternity and Infancy Protection Act in 1921. This marked the first attempt by the federal government to improve the welfare of mothers and babies. Almost a century later, concern about maternal mortality and persistent racial disparities have forced a reassessment. Elements of the long-abandoned care model are being reincorporated into modern practice, answering current health care dilemmas by heeding lessons from the past.
“Catchin’ babies” was merely one aspect of the broad role of African American midwives in the twentieth-century South. Yet, little has been written about the type of care they provided or how midwifery and maternity care evolved under the increasing presence of local and federal health care structures.
Using evidence from nursing, medical, and public health journals of the era; primary sources from state and county departments of health; and personal accounts from varied practitioners, Delivered by African American Midwifery in the Twentieth-Century South provides a new perspective on the childbirth experience of African American women and their maternity care providers. Author Jenny M. Luke moves beyond the usual racial dichotomies to expose a more complex shift in childbirth culture, revealing the changing expectations and agency of African American women in their rejection of a two-tier maternity care system and their demands to be part of an inclusive, desegregated society.
Moreover, Luke illuminates valuable aspects of a maternity care model previously discarded in the name of progress. High maternal and infant mortality rates led to the passage of the Sheppard-Towner Maternity and Infancy Protection Act in 1921. This marked the first attempt by the federal government to improve the welfare of mothers and babies. Almost a century later, concern about maternal mortality and persistent racial disparities have forced a reassessment. Elements of the long-abandoned care model are being reincorporated into modern practice, answering current health care dilemmas by heeding lessons from the past.
210 pages, Paperback
Published October 4, 2018
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December 12, 2021
This historical commentary documents the African-American lay midwives who practiced in the Deep South of the United States from the early 1920s until the revocation of their licensure and their forced retirement in the early 1970s.
4 stars for the history & 2 stars for the condescending tone = 3 stars overall
Written by a former nurse-midwife from Great Britain who is currently a history professor in Texas, this book provides a history of the African-American lay midwives, also called “granny” midwives, utilized by the government during the early to mid-20th Century to combat the high rates of maternal and child mortality in African-American communities in the Southern United States. It is well documented and contains 24 pages of endnotes and numerous photographs and diagrams. There is even an illustration showing how to make a bed pad from newspapers, which Margaret Charles Smith describes using in her book Listen to Me Good: The Story of an Alabama Midwife.
Beginning during the era of slavery in the southern United States, the book traces African-American lay midwifery from traditional and folklore-based practice through its modernization and medicalization with its temporary incorporation into institutional industrialized medicine, to its decline with the rise of hospital birth, and finally its loss of legal status through government prohibition. Lay midwifery's place within the context of the African-American community's concept of health is also explained. The author does a great job of describing the cultural shift from home to hospital birth during the mid-20th Century in which African-American women saw hospital birth with a physician as "represent[ing] an entrée into American society at large" (page 114) while white women saw hospital birth with a physician as a mark of wealth and homebirth with a midwife as a mark of poverty.
The analysis of healthcare is viewed through the lens of micro versus macro levels of care. The micro level is defined as direct patient interactions and care at the individual level, and the macro level is defined as the hierarchy and structure of the overall healthcare system and care at the institutional level. The meso/mezzo level, which would be care at the group/community level is omitted from the analysis.
While the history is excellent, the condescending tone with which the author discusses lay midwifery, which she seems to view both as a curiosity and, more importantly, as the precursor to her own field of nurse-midwifery, is disappointing. She casually repeats descriptions of lay midwives as "a necessary evil" (pages 68, 110) intended as a stopgap measure until white physicians could solve the problem of the high maternal death rates.
The subject and especially the women deserved more respect. The author manages to disparage lay midwifery — the apprentice track model consisting entirely of hands-on training without a formal degree — even as she praises the lay midwives, their willingness to learn and adopt new practices under government oversight, their ingenuity in overcoming their lack of resources and obstacles such as illiteracy, their dignity in the face of racism, their pride in their service to their communities, and their accomplishments in providing care and lowering the maternal and infant mortality rates. She also cannot resist throwing shade at direct entry and certified professional midwives and vilifying homebirth.
For example, in the introduction to section 1, the author writes:
“This book takes a perspective that exposes the value of community-centered, culturally appropriate, holistic care once discarded as archaic and backward that may have actually solved health-care needs much better than the wholesale regulation that came later would suggest. Moreover, it provides an opportunity to focus on black midwives, particularly the lay midwives, a group who proved themselves to be pragmatic in the face of adversity and ready to compromise as necessary. More often than not they impressed their superiors on a personal level, despite being collectively undervalued. They never lost sight of their objective to serve their communities to the best of their ability, and their unfaltering dignity and pride ultimately led them to personal triumph albeit at the expense of their own authority. An acknowledgment of the value of their working an attempt to rehabilitate some of the most effective aspects of their role suitably honors their lives.
Having introduced the scope, themes, and objective of this book, allow me to be clear about what it is not. This study of African American midwifery and maternity care is by no means a clarion call to return to homebirth and undereducated, inadequately trained midwives, far from it. (page 12)
In the same breath, the author acknowledges the African-American lay midwives as skilled clinicians and dismisses them as ignorant. Literacy doesn’t equal intelligence. Neither does a degree indicate medical knowledge and ability. Hence the joke, 'Question: What do you call a doctor who graduated last in his class from medical school? Answer: Doctor.'
Obstetricians, like lay midwives, have zero nursing experience, and they are not required to have any birth experience prior to medical residencies. Yet they are placed at the top of the birth attendant hierarchy. The author even states that physician-attended hospital birth increased the maternal rates rather than lowering them (page 26), acknowledges that historically doctors had much higher mortality rates than lay midwives (pages 56 -- 57, 112 -- 113), and omits the fact that presently, homebirths only account for 1% of all US births, which is considered statistically insignificant, meaning that the current abysmal maternal and fetal mortality rates are calculated from hospital births overseen by doctors.
The author also quotes the American College of Nurse-Midwives' 1980 statement that "having a master's degree was proven unrelated to clinical competency. Ultimately, though, it was implemented as a vehicle to enhance professional status rather than to improve the quality of care" (page 141). Nevertheless, she continues to call lay midwives improperly credentialed, ignorant, uneducated, and/or undereducated throughout the text. Twice she uses the phrase "catchin' babies" as a slur (pages 11 --12, 123), choosing to see it as a sign of ignorance and lack of medical skill rather than understand it as an acknowledgement that it is the mother who "delivers" the baby and not the birth attendant.
In the epilogue, the author insists that the future of midwifery is in the hands of nurse-midwives [like herself] and expresses hostility towards midwives from other educational backgrounds for jeopardizing midwifery's position as part of mainstream industrial medicine. Even though this is the typical attitude held by nurse-midwives towards their sister midwives from different educational tracks, I found this disappointing from someone who had spent over 100 pages documenting the tremendous success of lay midwives attending homebirths in improving maternal fetal outcomes. I had expected the author to acknowledge the value that lay midwifery has to contemporary midwifery practice rather than viewing it as a historical curiosity superseded by nurse-midwifery.
In contrast to Certified Professional Midwives (CPM), Certified Nurse-Midwives (CNM), and Certified Midwives (CM), lay (or traditional) midwives do not hold educational degrees or certificates, but they have thousands of hours of hands-on experience and training. They are competent health workers. As a bonus, they also possess the lived experience of the communities they served and are not separated from their patients by barriers of race, class, and gender (in the case of male doctors). As the author points out, nurse-midwives usually come from the middle-class and often lack knowledge and personal experience of the low income, low resource communities.
Based on the data presented, the recommendation to revive lay midwifery rather than entirely pass the torch to nurse-midwifery seems to be more in order. Hand skills are learned from hands-on training and not from textbooks and university lectures. One does not need a master's in nursing to take a blood pressure, measure a fundal height, and use a handheld doppler to monitor a fetal heart rate. Utilizing lay midwives, who either received training through apprenticeship or earned an associate's degree in midwifery, could dramatically increase access to prenatal and postnatal care, improve health outcomes, and reduce racial and ethnic disparities. Lay midwives could provide personal individualized care, flexibility, and repeated home visits during the weeks following birth.
Postnatal care is an area in which lay midwives could help make vast improvements. The World Health Organization (WHO) recommends 3 postnatal visits for both mothers and newborns: the first visit on day 3, the second visit on day 7 to 14, and the third visit on week 4 to 6. These are guidelines that the United States fails to follow. In an attempt to improve maternal health outcomes, the American College of Obstetricians and Gynecologists (ACOG) has recently changed their guidelines to recommend a 3 week check-up in addition to a 6 week check-up, but that has not altered the standard of care. US providers generally only see mothers at a single check-up 6 weeks after hospital discharge, and a recent 2019 study showed that only one-third of women felt their concerns were adequately addressed by their OB-GYN at their 6 week postnatal appointment. Lay midwives could conduct a series of postpartum appointments (either as home visits or in a clinical setting) and refer women and infants to nurse-midwives, a traveling nurse service, OB-GYNs, and pediatricians when medically indicated.
Public prenatal clinics, including mobile clinics, could be established and staffed by lay midwives. These midwives could work in collaboration with community health nurses who could address additional health needs and in collaboration with nurse-midwives and OB-GYNs who are willing to assume care for high risk patients or to whom care could be transferred in the event of complications.
In addition to providing prenatal and postnatal care, these clinics could also provide childbirth education, breasting education and support, and contraception. They could connect patients with local resources and social services.
Lay midwives are also members of the communities they serve, which endows them with the cultural competence to better understand the unique needs of their patients and provide better care. For example, while an OB-GYN may give patients the vague directive to eat well during pregnancy, a lay midwife would be better qualified to address the nutritional needs of a patient living in a "food desert." Doctors living in an upper-class suburban setting lack the experience of people living in rural or urban settings whose main source of groceries is the nearest dollar store, but a lay midwife would be able to counsel a patient on the best food choices through firsthand knowledge of availability.
The success of lay midwives in the 20th Century should not to be dismissively downplayed as a historical relic. The re-introduction of lower level midwives to combat the shamefully high maternal and infant mortality rates while at at the same time improving access to care and increasing diversity within the field is something worth considering.
4 stars for the history & 2 stars for the condescending tone = 3 stars overall
Written by a former nurse-midwife from Great Britain who is currently a history professor in Texas, this book provides a history of the African-American lay midwives, also called “granny” midwives, utilized by the government during the early to mid-20th Century to combat the high rates of maternal and child mortality in African-American communities in the Southern United States. It is well documented and contains 24 pages of endnotes and numerous photographs and diagrams. There is even an illustration showing how to make a bed pad from newspapers, which Margaret Charles Smith describes using in her book Listen to Me Good: The Story of an Alabama Midwife.
Beginning during the era of slavery in the southern United States, the book traces African-American lay midwifery from traditional and folklore-based practice through its modernization and medicalization with its temporary incorporation into institutional industrialized medicine, to its decline with the rise of hospital birth, and finally its loss of legal status through government prohibition. Lay midwifery's place within the context of the African-American community's concept of health is also explained. The author does a great job of describing the cultural shift from home to hospital birth during the mid-20th Century in which African-American women saw hospital birth with a physician as "represent[ing] an entrée into American society at large" (page 114) while white women saw hospital birth with a physician as a mark of wealth and homebirth with a midwife as a mark of poverty.
The analysis of healthcare is viewed through the lens of micro versus macro levels of care. The micro level is defined as direct patient interactions and care at the individual level, and the macro level is defined as the hierarchy and structure of the overall healthcare system and care at the institutional level. The meso/mezzo level, which would be care at the group/community level is omitted from the analysis.
While the history is excellent, the condescending tone with which the author discusses lay midwifery, which she seems to view both as a curiosity and, more importantly, as the precursor to her own field of nurse-midwifery, is disappointing. She casually repeats descriptions of lay midwives as "a necessary evil" (pages 68, 110) intended as a stopgap measure until white physicians could solve the problem of the high maternal death rates.
The subject and especially the women deserved more respect. The author manages to disparage lay midwifery — the apprentice track model consisting entirely of hands-on training without a formal degree — even as she praises the lay midwives, their willingness to learn and adopt new practices under government oversight, their ingenuity in overcoming their lack of resources and obstacles such as illiteracy, their dignity in the face of racism, their pride in their service to their communities, and their accomplishments in providing care and lowering the maternal and infant mortality rates. She also cannot resist throwing shade at direct entry and certified professional midwives and vilifying homebirth.
For example, in the introduction to section 1, the author writes:
“This book takes a perspective that exposes the value of community-centered, culturally appropriate, holistic care once discarded as archaic and backward that may have actually solved health-care needs much better than the wholesale regulation that came later would suggest. Moreover, it provides an opportunity to focus on black midwives, particularly the lay midwives, a group who proved themselves to be pragmatic in the face of adversity and ready to compromise as necessary. More often than not they impressed their superiors on a personal level, despite being collectively undervalued. They never lost sight of their objective to serve their communities to the best of their ability, and their unfaltering dignity and pride ultimately led them to personal triumph albeit at the expense of their own authority. An acknowledgment of the value of their working an attempt to rehabilitate some of the most effective aspects of their role suitably honors their lives.
Having introduced the scope, themes, and objective of this book, allow me to be clear about what it is not. This study of African American midwifery and maternity care is by no means a clarion call to return to homebirth and undereducated, inadequately trained midwives, far from it. (page 12)
In the same breath, the author acknowledges the African-American lay midwives as skilled clinicians and dismisses them as ignorant. Literacy doesn’t equal intelligence. Neither does a degree indicate medical knowledge and ability. Hence the joke, 'Question: What do you call a doctor who graduated last in his class from medical school? Answer: Doctor.'
Obstetricians, like lay midwives, have zero nursing experience, and they are not required to have any birth experience prior to medical residencies. Yet they are placed at the top of the birth attendant hierarchy. The author even states that physician-attended hospital birth increased the maternal rates rather than lowering them (page 26), acknowledges that historically doctors had much higher mortality rates than lay midwives (pages 56 -- 57, 112 -- 113), and omits the fact that presently, homebirths only account for 1% of all US births, which is considered statistically insignificant, meaning that the current abysmal maternal and fetal mortality rates are calculated from hospital births overseen by doctors.
The author also quotes the American College of Nurse-Midwives' 1980 statement that "having a master's degree was proven unrelated to clinical competency. Ultimately, though, it was implemented as a vehicle to enhance professional status rather than to improve the quality of care" (page 141). Nevertheless, she continues to call lay midwives improperly credentialed, ignorant, uneducated, and/or undereducated throughout the text. Twice she uses the phrase "catchin' babies" as a slur (pages 11 --12, 123), choosing to see it as a sign of ignorance and lack of medical skill rather than understand it as an acknowledgement that it is the mother who "delivers" the baby and not the birth attendant.
In the epilogue, the author insists that the future of midwifery is in the hands of nurse-midwives [like herself] and expresses hostility towards midwives from other educational backgrounds for jeopardizing midwifery's position as part of mainstream industrial medicine. Even though this is the typical attitude held by nurse-midwives towards their sister midwives from different educational tracks, I found this disappointing from someone who had spent over 100 pages documenting the tremendous success of lay midwives attending homebirths in improving maternal fetal outcomes. I had expected the author to acknowledge the value that lay midwifery has to contemporary midwifery practice rather than viewing it as a historical curiosity superseded by nurse-midwifery.
In contrast to Certified Professional Midwives (CPM), Certified Nurse-Midwives (CNM), and Certified Midwives (CM), lay (or traditional) midwives do not hold educational degrees or certificates, but they have thousands of hours of hands-on experience and training. They are competent health workers. As a bonus, they also possess the lived experience of the communities they served and are not separated from their patients by barriers of race, class, and gender (in the case of male doctors). As the author points out, nurse-midwives usually come from the middle-class and often lack knowledge and personal experience of the low income, low resource communities.
Based on the data presented, the recommendation to revive lay midwifery rather than entirely pass the torch to nurse-midwifery seems to be more in order. Hand skills are learned from hands-on training and not from textbooks and university lectures. One does not need a master's in nursing to take a blood pressure, measure a fundal height, and use a handheld doppler to monitor a fetal heart rate. Utilizing lay midwives, who either received training through apprenticeship or earned an associate's degree in midwifery, could dramatically increase access to prenatal and postnatal care, improve health outcomes, and reduce racial and ethnic disparities. Lay midwives could provide personal individualized care, flexibility, and repeated home visits during the weeks following birth.
Postnatal care is an area in which lay midwives could help make vast improvements. The World Health Organization (WHO) recommends 3 postnatal visits for both mothers and newborns: the first visit on day 3, the second visit on day 7 to 14, and the third visit on week 4 to 6. These are guidelines that the United States fails to follow. In an attempt to improve maternal health outcomes, the American College of Obstetricians and Gynecologists (ACOG) has recently changed their guidelines to recommend a 3 week check-up in addition to a 6 week check-up, but that has not altered the standard of care. US providers generally only see mothers at a single check-up 6 weeks after hospital discharge, and a recent 2019 study showed that only one-third of women felt their concerns were adequately addressed by their OB-GYN at their 6 week postnatal appointment. Lay midwives could conduct a series of postpartum appointments (either as home visits or in a clinical setting) and refer women and infants to nurse-midwives, a traveling nurse service, OB-GYNs, and pediatricians when medically indicated.
Public prenatal clinics, including mobile clinics, could be established and staffed by lay midwives. These midwives could work in collaboration with community health nurses who could address additional health needs and in collaboration with nurse-midwives and OB-GYNs who are willing to assume care for high risk patients or to whom care could be transferred in the event of complications.
In addition to providing prenatal and postnatal care, these clinics could also provide childbirth education, breasting education and support, and contraception. They could connect patients with local resources and social services.
Lay midwives are also members of the communities they serve, which endows them with the cultural competence to better understand the unique needs of their patients and provide better care. For example, while an OB-GYN may give patients the vague directive to eat well during pregnancy, a lay midwife would be better qualified to address the nutritional needs of a patient living in a "food desert." Doctors living in an upper-class suburban setting lack the experience of people living in rural or urban settings whose main source of groceries is the nearest dollar store, but a lay midwife would be able to counsel a patient on the best food choices through firsthand knowledge of availability.
The success of lay midwives in the 20th Century should not to be dismissively downplayed as a historical relic. The re-introduction of lower level midwives to combat the shamefully high maternal and infant mortality rates while at at the same time improving access to care and increasing diversity within the field is something worth considering.
November 19, 2025
Eye opening
Read
September 23, 2019Anyone interested in the ebb and flow of African-American midwifery in the South should find this book highly useful. A scholarly work, but quite readable by the general public, it describes the work of the Grand Midwife after the Civil War, through the beginnings of the state public health apparatus, through mandatory licensing and eventual cancellation of those licenses, and the reinvention of the midwife in various forms.
Most compelling is the view of the relationships between various health care professions and institutions as they gain or lose authority: the Grand Midwives themselves, physicians of various flavors prior to consolidation by the AMA, African-American physicians, public health nurses, hospitals, midwives' clubs, and, of course, the patients/clients served by these entities. The author takes a particularly probing view of the "macro-micro" relationships that midwives found themselves enmeshed in; while connected on the micro level to the poorest, most remote families at home, for whom they provided a culturally-specific and individualized model of care, they also served as a link to the "macro" world of public health officials, hospitals, and physicians. The value of this connective service became especially noted when it ceased to exist:
The racial disparities in birth outcomes we see today were planted in the years when midwives were taken away from their clients.
In examining the rise of nurse-midwives, the author looks carefully at the exclusion of midwives of color from their rank, referencing Mary Breckenridge's racialized pursuit of Appalachian patients who would serve as "an antidote to the forecasted weakening of American stock." The increasing professionalization of nurse-midwives, with the real possibility of a doctoral degree requirement in the near future is another barrier to access to the profession by a diverse array of students.
It is unfortunate that the book does not include any information about Certified Professional Midwives, stating that home births have become the province of middle-class white women. Particularly given the activity in various professional organizations of midwives over the last several years to cope with questions of inclusion and exclusion, it seems a pity to leave out a certification that is financially, at least, in easier reach for women of color wishing to become midwives.
Most compelling is the view of the relationships between various health care professions and institutions as they gain or lose authority: the Grand Midwives themselves, physicians of various flavors prior to consolidation by the AMA, African-American physicians, public health nurses, hospitals, midwives' clubs, and, of course, the patients/clients served by these entities. The author takes a particularly probing view of the "macro-micro" relationships that midwives found themselves enmeshed in; while connected on the micro level to the poorest, most remote families at home, for whom they provided a culturally-specific and individualized model of care, they also served as a link to the "macro" world of public health officials, hospitals, and physicians. The value of this connective service became especially noted when it ceased to exist:
Their role as educators and communicators, all enhanced by contact with the larger medical system, was left void when they were officially prevented from practicing. Their consistent presence, their role as liaisons, and their expertise on cultural mores were now removed from maternity care.
The racial disparities in birth outcomes we see today were planted in the years when midwives were taken away from their clients.
In examining the rise of nurse-midwives, the author looks carefully at the exclusion of midwives of color from their rank, referencing Mary Breckenridge's racialized pursuit of Appalachian patients who would serve as "an antidote to the forecasted weakening of American stock." The increasing professionalization of nurse-midwives, with the real possibility of a doctoral degree requirement in the near future is another barrier to access to the profession by a diverse array of students.
It is unfortunate that the book does not include any information about Certified Professional Midwives, stating that home births have become the province of middle-class white women. Particularly given the activity in various professional organizations of midwives over the last several years to cope with questions of inclusion and exclusion, it seems a pity to leave out a certification that is financially, at least, in easier reach for women of color wishing to become midwives.
December 16, 2023
Jenny Luke focuses on the demise of midwifery as a Black and White issue. She believes that the inherent racism of the South created a unique environment that allowed a very particular style of maternity care to emerge. This book charts the shift from micro-level care to micro/macro blend to macro care. Luke believes the value of community-centred, culturally appropriate, holistic care would solve the needs of the modern day.
Honestly, this wasn't my favourite book. I feel like Luke could have done a lot more. She lacks Black midwifery primary sources in their voice and relies heavily on medical and nursing journals. She has so many chapters that are only a few pages long, I believe she is spreading herself too thin. If she had focused on only a few things she could have fleshed them out more. Luke does a great job of acknowledging that African-American midwives contributed to American society. I don't know if Luke adds much to the field with this work though. Other books have done the same.
Honestly, this wasn't my favourite book. I feel like Luke could have done a lot more. She lacks Black midwifery primary sources in their voice and relies heavily on medical and nursing journals. She has so many chapters that are only a few pages long, I believe she is spreading herself too thin. If she had focused on only a few things she could have fleshed them out more. Luke does a great job of acknowledging that African-American midwives contributed to American society. I don't know if Luke adds much to the field with this work though. Other books have done the same.
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