Birth | An Excerpt from the Big Ideas & New Perspectives Category

For decades, doctors had publicly played on prejudice, wielding xenophobia, racism, and sexism in a bid to eradicate midwifery altogether and claim dominion over childbirth. However, their unwillingness to serve poor Black women in rural areas meant midwives remained a tolerated necessity in some parts of the country. In 1921, the US passed the Sheppard-Towner Maternity and Infancy Act, which was meant to benefit poor women and children with prenatal and child health clinics and improve funding for nutrition and hygiene education, as well as regulate midwifery training in rural areas. At this point, most northern women were giving birth in hospitals. Of the sixty thousand midwives who still practiced in the US, most lived in the South. The practice of lay midwifery rested almost entirely in the hands of African American “grand” midwives like Onnie Lee Logan and Margaret Charles Smith, who delivered thousands of babies over the course of their careers. 

Midwives like Logan and Smith were highly skilled, trusted, and respected figures who served any mother, regardless of where she lived or if she was able to pay. Logan was born around 1910 near Sweet Water, Alabama, the fourteenth of sixteen children. Logan’s mother and grandmother were midwives, and she went to births with her mother from a young age. At twenty-one, she began practicing on her own, but because she mostly attended poor families who could not pay much for her services, she earned income through domestic work for white families, as many grand midwives did. Then, in 1949, Logan received a midwifery license from the Alabama Board of Health and served as the primary maternal healthcare provider for Prichard and Crichton, predominately Black areas around Mobile. She lost only one baby in forty years of practice. 

Smith got her start in midwifery when she was just five years old, after catching a neighbor’s baby before the midwife arrived in her town of Eutaw, Alabama, about 165 miles north of Mobile. Smith also received a midwifery permit in 1949 and went on to practice for thirty-five years, attending nearly three thousand births. She became known as the midwife “who never lost a mother and rarely lost a baby.” 

The outstanding records of both of these grand midwives were even more impressive given the conditions under which they worked. They were sometimes called to deliver babies in isolated homes without running water or electricity and had to be resourceful and adaptable. (One clever technique to gauge whether a cloth had been adequately sterilized was to put a potato in the oven along with it—when the potato was cooked through, the cloth was safe to use.) And they had limited options for what to do if there were serious complications. Because local hospitals would not accept Black patients, Smith had to transport women to the Tuskegee hospital—170 miles away—in the event of an emergency. 

There were strict state guidelines they had to follow as well, which limited the scope of their practice. They could not use instruments or administer drugs. They were subject to strict uniform and bag inspections and discouraged from maintaining traditional or folk practices, such as using herbal teas to augment labor. The rules helped legitimize the profession, and many midwives embraced them because protocols around hygiene and asepsis helped to reduce infection rates and save lives, but the intense supervision and hierarchy was also patronizing, and contributed to the idea that midwifery was inferior to obstetrics. 

By 1938, there were thirty-five thousand midwives left in thirty-four states; they attended 9 percent of all births: 3 percent white, 9 percent “other” races, 50 percent Black. Midwives continued to practice in the South in mid-century America, but their numbers—and those of their clientele—steadily dwindled. By the 1960s, it was almost unheard of for women to deliver with a lay midwife at home outside of isolated rural areas and specific religious communities, like the Mennonite and Amish. Fewer than 1 percent of births each year happened outside the hospital, which had become the norm for women across geographies, races and ethnicities, income levels, and social classes. 

Then the hippie, feminist, civil rights, and anti-war movements of the late 1960s and ’70s arrived. The counterculture sowed a widespread distrust of authority and a willingness to challenge the establishment, leading to a surge in consumer activism and an interest in the ideal of more natural, authentic living through getting back to the land, which led to a renewed interest in midwifery. 

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When lay midwifery reemerged onto the national stage in the 1970s, it reemerged as a primarily white, middle-class phenomenon. There were midwives, activists, and advocates, like the midwife Shafia Monroe, who promoted Black midwifery and home birth as part of a larger effort to promote health activism and self-reliance within African American communities, but for the most part, preferences were moving in the opposite direction. The passage of the Civil Rights Act and Medicare and Medicaid in the mid-’60s made hospitals more accessible, which, according to the anthropology professor Dr. Gertrude Fraser, “signaled a symbolic if not fully realized inclusion in the field of vision of a health-care bureaucracy that had until then largely ignored the health needs of African Americans.” The opportunity to give birth in a hospital was seen as a sign of progress. Midwives were no longer needed to fill in gaps in care, which created an opportunity for states to pass laws outlawing the practice for good. In 1976, Alabama—where Logan and Smith served their communities for decades—stopped issuing licenses to new midwives, stopped renewing the licenses of current midwives, and revoked licenses outright. Over 150 senior midwives—all Black women—were forced to retire. “Nothing in my life has ever made me feel so little,” Logan said about the retirement letter she received. 

Excerpted from Birth: Three Mothers, Nine Months, and Pregnancy in America. Copyright © 2023 by Rebecca Grant. Published by Avid Reader Press, an Imprint of Simon & Schuster, Inc. All rights reserved.