Historical Background

Midwifery existed well before the history of the United States began and was practiced in a variety of ways by midwives of Indigenous, African, Asian, and European descent. Ever present has been the story of practitioners seeking to do right by their patients, while simultaneously providing care within institutionalized structures that systematically disempowered and disenfranchised women and people belonging to marginalized backgrounds.

Midwifery was practiced by women who often did not have the means or privilege to leave behind an archival record of their work. In 18th and 19th century America, many midwives were enslaved women and were often called “Granny” midwives. Through the care they were expected to provide, they drew from their personal experience and intergenerational expertise to help other enslaved women.

Enslavers also held an interest in using the labor midwives provided to protect the continuity of a plantation’s “business” – namely, by ensuring the healthy delivery of babies and recovery of women in childbed. Some enslaved midwives were paid, as was the case with Kate, a woman enslaved by George Washington. In 1794, Washington recorded that Kate was to be paid between £12 and 15 per year for her services.

During the same time, free white midwives were paid roughly £10 per delivery. In the late 18th-century, a free white midwife might find financial independence and personal affirmation through her work, as was the case for Martha Ballard, who worked as a midwife and medical examiner in Maine and wrote of her career in a diary, which she kept every day for 27 years, from 1785 to 1812.

After Reconstruction, the role of Granny midwives persisted in African American communities, and they often were the only point of care for Black and white pregnant people in rural areas. In a blog post, the National Museum of African American History and Culture points out that “birth workers traditionally occupied a prominent position in African American communities, serving as healers and spiritual leaders, and maintaining extensive social networks.”

The rise of obstetric and gynecological (OB-GYN) medicine in the 19th and early 20th century, however, brought more men into a role of overseeing births, particularly in hospitals. Over time, the male-dominated OB-GYN medical establishment systematically robbed midwives of their power as community healers by passing laws requiring licensure, painting midwives who practiced without a license as dangerous and uneducated.

In the 20th century, midwifery practitioners sought to overcome the barriers set in place by the medical establishment. White midwifery advocates established nurse-midwifery as an education pathway for white midwives in the 1920s, enabling the role of midwife to become recognized in hospital settings. However, the formalized structure of midwifery education, in combination with the decision to allow each state to regulate its own midwifery laws, presented profound barriers for midwives of color during a time when institutionalized racial segregation existed throughout the United States. By the 1950s, midwives of color began to gain greater access to midwifery certification, as hospitals were forced to integrate. State health departments and medical education associations sought to bridge highly regulated midwifery educational systems with the experience-based practices of Granny midwives.

A midwife continues to serve as a vital link of the community of care centered around a person who is pregnant. However, health disparities faced by patients of color, particularly Black women, remains a persistent force. According to 2022 data from the CDC, Black women face a 3 to 1 mortality rate compared to white women, while a 2020 CDC study reported that Black midwives only made up 7% of all CNMs/CMs in the U.S. Promoting midwifery education among practitioners who reflect and listen to the community they are seeking to serve is just one way to help ensure positive health outcomes for Black women.

Historical Background

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