Nothing to Work With but Cleanliness: The Training of African American Traditional Midwives in the South

THE PRACTICE OF MIDWIFERY came under public scrutiny during the 1910s when Progressive reformers collected birth and death statistics to agitate for diverse ideas of health reform. Physicians tended to attribute high infant and maternal mortality rates in the United States to the “unsanitary and superstitious” practices of traditional midwives. At a time when most women gave birth at home, medical and public health professionals argued that getting rid of the midwives would yield noticeable improvements in maternal and infant care.

By the early 1920s the terms “granny,” and “granny-midwife” were synonymous with black midwives in the rural South. In Northeastern cities, midwives were largely displaced by physicians working in hospitals; many women considered hospital births the “modern” and “advanced” form of delivery. But midwifery persisted in Southern rural communities, where the majority of African American midwives practiced. Few physicians—white or black—were willing to attend births for the two or three dollars per delivery that midwives would accept. (Indeed, midwives would sometimes be given a chicken as payment or not be paid at all.) African American mothers also preferred home births to hospital deliveries because they could avoid the prejudice and discrimination they often experienced in White society.

A midwife training institute being conducted in a church. Photograph by E.S. Powell, for the South Carolina State Board of Health, circa 1940. Courtesy of the American College of Nurse-Midwives Archives, National Library of Medicine.

Finding they were unable to eradicate midwifery, reformers compromised by making traditional midwives register with local health departments to obtain a permit and attend classes at local midwife clubs and state training institutes. Midwife clubs supported and also regulated midwives. The nurse-midwife or public health nurse instructed her pupils to maintain the clean and sterile standards required for practice. Midwives were expected to be “clean in person, home, and equipment,”¹ and to wear a white cap and white starched apron over a clean dress. They were to carry properly stocked black leather bags; these bags—as well as the midwives’ homes—were inspected for cleanliness. Classes at state-sponsored midwife institutes were taught primarily through demonstrations, role playing, and songs because most traditional midwives had little formal education.

The 1921 Sheppard–Towner Maternity and Infancy Protection Act provided matching funds to state health departments for midwife training programs. The states established training and regulatory programs in which public health nurses taught midwives to use sterile procedures, register new births with the state, use silver nitrate eye drops to prevent gonococcal blindness, and seek physician assistance for difficult cases. The top image shows a midwife training program being conducted in a church. State health officials may be seen in the front pew; ranked beside and behind them sit the public health nurses and the midwives in their white aprons.

Community women and their babies attending a postnatal class. Photograph by E.S. Powell, for the South Carolina State Board of Health, circa 1940. Courtesy of the American College of Nurse-Midwives Archives, National Library of Medicine.

Midwives trained under the Sheppard–Towner Act and later with funding from the Social Security Act (1935) served as educators to expectant mothers and community residents in African American communities throughout the South. As community health educators, they encouraged women to seek prenatal and postnatal care, accompanied them to clinics as needed, and explained the nature and significance of the visits. In the bottom image, community women and their babies attend a postnatal class. African American midwives actively promoted health by sponsoring child immunization clinics in their homes, providing nutrition education, and notifying public health nurses of bedridden residents in their communities—as well as by delivering healthy babies. Traditional midwives became a vital force in the federal government's efforts to improve the health of African Americans.