Where have all the midwives gone? The campaign against Black midwives and its impact on Black maternal outcomes
Midwives attended more than half of births in the U.S. in the 1920s. Black midwives, like the renowned Mary Francis Hill Coley, pictured above, played a central role. A concerted effort to discredit midwives as incompetent and dangerous, however, significantly reduced their numbers. Photo: Collection of the Smithsonian National Museum of African American History and Culture, Gift of Robert Galbraith.
As increasing attention at the national and state level is focused on the racial disparities in maternal health care, New Jersey continues to be plagued with staggering maternal and infant mortality rates. Currently ranked 29th in the country for maternal deaths, New Jersey has one of the widest racial disparities for maternal and infant mortality, with Black mothers in New Jersey nearly seven times more likely than White mothers to die from maternity-related complications. Black babies in New Jersey are nearly three times more likely than White babies to die before their first birthday.
To improve maternal and infant outcomes and address these racial disparities, Black mothers, birth justice activists and a growing number of medical associations have advocated for a return to increased use of midwifery care, given the positive outcomes associated with midwife-assisted births. In New Jersey, the administration of Gov. Phil Murphy has included the strengthening and expansion of midwifery as a recommendation to eliminate racial disparities in maternal outcomes in its 2021 Nurture New Jersey Strategic Plan.
While the percentage of midwifery-assisted births has increased in recent years, choosing to give birth with a midwife today remains outside of usual practice both in New Jersey and across the United States. In the U.S. approximately 12% of women give birth with assistance from a midwife, and in New Jersey that number is approximately 9%. The dominance of obstetrician-gynecologists as the primary perinatal care provider is, however, a recent phenomenon.
From the beginning of time, midwives (literally meaning a woman who is with the birthing mother, derived from Middle English mid, meaning “with,” and wif, meaning “woman”) have held the role of providing care to women during pregnancy and birth across the globe. It was not until the 19th century that the field of obstetrics began to take hold in the United States, and midwives were sidelined from what had been nearly exclusively their domain for centuries. In their paper “African-American Midwifery, a History and a Lament,” sociology professors Keisha Goode and Barbara Katz Rothman write: “Wherever there have been women, there have been midwives. The history of maternity care is thus the history of midwifery, at least until the 17th century in Europe and the 19th century in the United States. The rise of obstetrics was the fall of midwifery, women’s loss of control over procreation to men’s hands and to men’s tools.”
From the beginning of the African American experience, Black midwives have played a central role in birth in the U.S. African midwives who survived the middle passage brought with them their traditions and experience, which they passed on to other women once they arrived in North America. During slavery, Black midwives provided critical care to enslaved women, including holistic prenatal care and care during birth, and often attended the births of slave masters’ wives as well. These midwives were highly respected members of their community, relied upon for their healthcare services, which went well beyond pregnancy and childbirth, as well as for their spiritual and moral guidance, part of their holistic approach to community-based care. Unlike most enslaved people, Black midwives were often permitted to travel during this time and were even paid for their services on occasion.
Following the end of slavery, Black midwives continued to act as the primary providers of care for pregnant women. These midwives were termed “granny midwives”, a name that White medical professionals employed in a derogatory sense to denigrate the midwives based on their race.
The Campaign Against Midwives
Over the course of the 19th century and into the 20th century, White male doctors took an increasing interest in the business of birth, developing what would eventually become the field of obstetrics. As the obstetric project advanced, birth was portrayed as something that necessitated management by those with particular professional qualifications, regardless of lived experience. In the mid to late 19th century as the American Medical Association officially recognized obstetrics as a part of the association and the American Association of Obstetricians and Gynecologists was established, doctors hoping to practice in this new field faced the reality that midwives were still handling the majority of births. During this time, amongst frustrations that midwives were taking away from the prestige of the field, and thus stopping obstetrics from becoming a respected and well-paid specialization, the medical elite began discussing how to solve the “midwife problem.”.
What ensued was a concerted effort to discredit midwives as incompetent and dangerous. The introduction of germ theory at the end of the 19th century further facilitated efforts to paint midwives as unskilled and unsafe, as opposed to doctors and hospitals, which represented cleanliness, safety and expertise. Birth was something to be feared, something that could be properly managed only by doctors.
This campaign to delegitimize midwives was rooted in unabashed racism. In 1919, Dr. Henry Borst published an article in the Pensacola Journal recommending that Florida “handle the Ignorant negro midwife question in a sensible manner, by requiring them to go through hospital training before being allowed to do ‘granny’ malpractice.”
In the 1920s, the director of the Bureau of Child Hygiene for Mississippi wrote in the book, “The Development of Midwifery in Mississippi”: “What could be a more pitiable picture than that of a prospective mother housed in an unsanitary home and attended in this most critical period by an accoucheur, filthy and ignorant, and not far removed from the jungles of Africa, laden with its atmosphere of weird superstition and voodooism.”
Racist, anti-midwife rhetoric ignored the positive outcomes associated with midwife-assisted birth. Several studies in the early 20th century by public health institutions demonstrated that maternal and infant mortality rates did not drop when doctors attended births. Some of this data, in fact, showed that midwife-assisted birth was safer. For example, midwives in Newark between 1914-1916 achieved maternal mortality rates of 1.7 per 1,000 births, whereas rates in Boston, where midwives were banned, were 6.5 per 1,000. Infant mortality rates in Newark were 8.5 per 1,000, compared to 36.4 in Boston.
The negative outcomes associated with births managed by obstetricians were also ignored. Contrasted with the rich, hands-on experience of apprentice midwives, newly minted obstetricians graduating medical school often had little to no experience attending births. Dr. Linda Holmes, nationally recognized author on maternal care, women’s health activist and former director of the New Jersey Office of Minority and Multicultural Health, chronicles the fall of Black midwifery in her groundbreaking book co-authored with Alabama midwife Margaret Charles Smith “Listen to Me Good: The Story of an Alabama Midwife.” Holmes says that despite data showing that mortality rates for White mothers and babies receiving private care were higher than rates from poor and rural Black women having midwife-supported births, “doctors were never scrutinized like midwives.”
Dr. Goode notes in “African American Midwifery” that it was not until the end of World War II that birth safety numbers “recover[ed] from the damage caused by medicalization,” with the mortality rate of doctor-assisted births finally falling to the rate of midwife-assisted births.
Despite these facts, the campaign against midwives, rooted in and propelled by racism against the Black midwives who had made up a significant portion of the profession, was successful.
Ever-increasing training and licensing requirements across the country, beginning with the 1921 Sheppard-Towner Maternity and Infancy Protection Act, made midwifery practice more and more unattainable for many midwives, particularly those who were Black. Public health authorities began turning to nurses, who were seen as superior to midwives, to supervise and monitor midwives. What was eventually born was the nurse-midwife, a regulated profession which required a nursing degree with a specialization in obstetrics, which is the dominant form of midwifery in the United States today.
Because of segregation, most nurse-midwifery schools that opened in the 1930s and 1940s did not accept Black women. Even in the few Black programs, there were strict requirements for admission, including age and health requirements that automatically disqualified many Black midwives who had been practicing for decades. The cost of these programs was also prohibitive for a large portion of Black midwives, particularly those practicing in poor, rural areas. The result for the majority of Black midwives was that they were gradually excluded from practice despite their extensive experience, as many states eventually outlawed practice by “lay” midwives without a nurse-midwife certification.
Black midwives who did manage to graduate and obtain the certification of nurse-midwife faced the same barriers of discrimination in employment faced by Black Americans in other professions.
With the passing of the Hill-Burton Act of 1946, which provided federal funds for the construction of hospitals in rural areas, the percentage of hospital births skyrocketed from 37% in 1935 to 88% in 1950, according to data from the Centers for Disease Control. Moving birth out of the home and into the hospital was the end of widespread midwifery-assisted birth in the U.S.
The Legacy of Anti-Midwife Rhetoric in New Jersey
The medicalization of birth and of midwifery care continues to make access to the profession and to midwifery care difficult in New Jersey. There has been a recent push by Governor and First Lady Murphy to promote the benefits of midwifery and expand midwifery practice as part of the administration’s 2021 strategic plan to address the state’s maternal and infant mortality crisis. Important steps include the 2023 change to increase New Jersey Medicaid reimbursement rates for both doctors and midwives to match 100% of current Medicare rates for certain maternity-related services, and an implementation of pay parity so that midwives receive the same reimbursement rates as doctors for all covered services. Still, significant challenges remain.
One is the distinctions in certifications of midwives, which impact how each kind of midwife can practice. In New Jersey, there are three types of midwives that are licensed: certified nurse midwives (CNMs), certified midwives (CMs) and certified professional midwives (CPMs). CNMs and CMs both complete a graduate-level midwifery program and take the same certification exam, with the difference being that CNMs are also qualified nurses while CMs are not. Alternatively, CPMs go through a different certification process through the North American Registry of Midwives.
In New Jersey there are approximately 400 licensed midwives, 90% of whom are CNMs, reflecting their dominance in the profession nationwide. While the scope of practice of CNMs and CMs is the same, CMs do not have the prescription power that CNMs hold, and cannot currently practice in the majority of hospitals in New Jersey, despite the fact that the state Department of Health signed a universal waiver in 2020 allowing CMs to exercise the same authority as CNMs in licensed facilities.
“The problem is that many hospitals haven’t changed their bylaws, and still solely make reference to certified nurse-midwives,” says. Dr. Julie Blumenfeld, CNM and program director of Rutgers’ Nurse-Midwifery Program. “While the waiver is fabulous, it remains a waiver, and hospital systems are individually left to decide whether to hire CMs. So there may be a hospital administrator who doesn’t understand CNMs and CMs have identical certification and misses the opportunity to hire a CM. What would really be helpful is just to refer to midwives as midwives, allowing them to practice autonomously to the full extent of their education and clinical training, and certification.”
Blumenfeld, who is also the president of the New Jersey Affiliate of the professional association American College of Nurse-Midwives, which represents CNMs and CMs, says some hospital administrators have told her they are not comfortable hiring CMs given that they do not have a nursing background. However, a significant portion of CNMs have never worked as a nurse, and became nurses only in order to obtain the CNM midwifery certification. “There is a lot of changing of hearts and minds to be done, which precedes changing of policy,” Blumenfeld notes, “and changing of culture is challenging.”
New Jersey midwives are also unable to practice independently without an agreement with a consulting physician. “The majority of states in the U.S. have changed their regulations or legislation so that midwives can practice independently, understanding that independent practice leads to more desirability to work in a state, and growing the midwifery workforce is one way to move the needle, improving poor maternal health outcomes and eliminating racial disparities,” Blumenfeld says. Legislation put forward in New Jersey last year to permit independent midwifery practice was unsuccessful, despite positive examples from other states and the lack of data indicating that a supervising physician improves safety.
Using Midwifery to Address Racial Disparities
When thinking about the causes of the Black maternal mortality crisis, birth justice advocate Linda Locke is clear. “What’s been identified as a central cause of the crisis is not being listened to,” says Locke, the former chief of the Midwifery Section at St. Joseph’s Regional Medical Center in Paterson. “When Black women have a problem, they’re not taken seriously. They’re not seen as valuable. It’s really the systemic racism that we have in this country that is causing it.”
Throughout her more than 40-year career in New Jersey as a CNM, which included running her own private practice for a decade, Locke was one of only a few other Black midwives wherever she practiced. Little progress has been made in diversifying the workforce, with only 7% of CNMs and CMs nationally identifying as Black or African American.
When Locke attended midwifery school in the mid 1970s, the history of Black midwives was not included in the school’s course on history of midwifery in the U.S. “When the American College of Nurse Midwives honored the legacy of Black midwives at their 2018 Annual Meeting in Savannah, I really didn’t think I would see that in my lifetime. It is so important for us to know the history of Black and Native midwives. There has been a concerted effort to erase our history, because you gain strength from the knowledge of your history, knowing that it is part of you. We didn’t just land here as blank slates. We brought so much with us.”
The midwifery model of care, practiced by Black midwives from the moment they arrived on the continent, continues to yield improved maternal and infant outcomes. Recent studies have shown that midwifery-led care across high, middle and low-income countries results in lower risk of postpartum hemorrhage, birth asphyxia, emergency cesarean sections and decreased average time in the neonatal intensive care units. Midwifery care not only improves outcomes for mothers and babies in general, but has also been shown to address racial disparities in care, as outlined in New Jersey Health Care Quality Institute’s 2022 report on midwifery care as a driver of change in the state’s maternal health crisis.
“What midwives bring to the table is that we listen to women”, says Locke, who is the vice chair of New Jersey’s Maternal Mortality Review Committee. “We trust women's bodies to be able to birth, so we have lower C-section rates, and we know operative birth is higher-risk and more linked with complications.” Locke notes that midwifery practices like the ones she used to oversee do not limit their care to low-risk patients. Some of Locke’s patients had significant complications, which were effectively managed through positive collaboration with other specialists when needed.
Dr. Joyce Hyatt, now retired CNM, author and former program director of Rutgers’ Nurse Midwifery Program, also highlights midwifery’s woman-centered approach as key to its effectiveness. “Midwives are caring for the individual woman, taking into consideration her unique circumstances, the circumstances of her family. And also providing her with information along the way. The education piece is critical to obtaining better outcomes.” Hyatt notes that the personal relationship that midwives often have with their patients also has an impact on the quality of care. “Women often feel more comfortable sharing certain information with us as midwives. So this kind of privileged relationship improves the care we provide.”
The activism and advocacy of Black women and Black midwives in New Jersey has led to an increased prioritization of policy efforts meant to address the vast racial disparities in maternal and infant outcomes. While much work remains in order to fully implement the recommendations put forward, Locke is hopeful.
“One thing that gives me hope is that the push to have more Black midwives and better outcomes is being led by the Black women who are themselves affected. We rose up and said, ‘We are claiming this issue.’ Many people used to say that these disparities existed because Black women were innately high-risk, that we were the issue. But we have made it clear that it is not our race that is the problem, it is racism. We identified that it was the system and how it reacts to us that was the problem, and raised our voices loud enough so that they could not be ignored. Seeing that and seeing the younger midwives coming along with a kind of fire, committed to making a difference, that’s what gives me hope.”
