Until the first decades of the 20th century, most of the children born in the South—and nearly all born in the rural South—were delivered by midwives. Sometimes family friends, sometimes acknowledged experts in the community, and often both, midwives provided essential medical care to isolated or impoverished communities. However, in less than 70 years, independently operating midwives were all but gone.
The practice of midwifery, argues Debra Anne Susie, was a victim of industrialization in America and the infiltration of mass production into every aspect of American life. Midwives were craftswomen, providing specialized services to populations that needed them. The professionalization of medicine, increasing regulation by state governments, and the rise of an American reliance on technology and the accompanying belief in the power of modern science combined to gradually erode public confidence in midwives—contrary to what health statistics bore out for decades.1
In areas of noticeably high immigrant populations such as large northern urban centers, midwives became associated with backward, Old World beliefs. In the South, as more and more middle-class mothers opted for hospital deliveries, midwifery came to be associated with lower-class whites and African-Americans.2 Indeed, by the first decades of the 20th century most midwives in Florida were African-American women who served predominantly African-American communities, and as caregivers of last resort for whites and blacks. Even still, in small towns and rural areas throughout Florida, midwives remained honored members of the community, remembered by the babies they delivered and town leaders often for decades after they died.
The national effort toward the licensing of midwifery that began in the 1920s and 1930s was pushed by many of its earliest supporters from the ranks of professional physicians as a means of closely scrutinizing and tracking midwives until the eventual elimination of approaches and traditions not in keeping with accepted obstetrical practices. Florida’s first Midwifery Law was passed in 1931, although the State Board of Health had been interested in monitoring midwives since 1915 when it hired four nurses to travel the state to supervise midwives. The new statute of 1931, however, required the licensure of midwives, whereas it had been voluntary before, and established new qualifications such as familiarity with a training manual and the attendance of at least 15 births with a registered physician. Prior to the new law, inspections of midwives' homes and methods under the direction of the Bureau of Education and Child Welfare had already pushed many midwives out of the profession, and the 1931 statute represented an intensification of regulation of midwives.3
In 1933, the state began offering classes at the “midwife institute” established at Florida A&M University in Tallahassee, and the state held other institutes regionally in cities such as Tampa and St. Augustine. Classes emphasized basic principles of hygiene such as the importance of sterilizing equipment. Despite unquestionable success in attracting young midwives from around the state, the institute was permanently discontinued in 1946, replaced with local and county level supervision. County health nurses trained midwives as pregnancy and delivery became more carefully measured and supervised medical procedures, most often conducted within the hospital setting. The nurse-midwife was a compromise of sorts, between traditional midwives and increasingly professionalized, physician-administered birth practices throughout the nation and in Florida, although midwives in the South and Florida recognized that their profession, which had sometimes been passed down for three or four generations of midwives in one family, was being eliminated by the state and health care professionals.4
Among various strategies used by state and local officials, “voluntary honorable discharge” and “doctor permits” were two state programs intended to bring midwives and their relationships with expectant mothers under state supervision. The “honorable discharge” process facilitated the transfer of a traditional, or “granny midwife’s” practice to a younger, professionally trained midwife. Retired midwives were encouraged to give their equipment to the younger practitioners in order to avoid the temptation of practicing again, while creating the semblance of a ritual transfer of the traditional role as a community leader. Under the “doctor permit” practice, midwives were required to receive medical clearance from a physician certifying that an expectant mother’s pregnancy was “low risk” after a hospital visit. However, during the hospital visits, patients were shown the advantages of hospital births and physicians increasingly granted fewer and fewer permits for “low-risk” midwife deliveries.
By the 1970s, traditional, or “lay” midwives had almost disappeared in Florida. Over several decades, midwifery was increasingly pressured by governmental regulation and became less popular than hospital deliveries, even among the rural and impoverished mothers who had so long relied on midwives for safe deliveries. No extensive regional or national studies ever established that physician-administered hospital deliveries significantly lowered infant mortality numbers or improved the health of newborns and their mothers for low risk pregnancies and normal deliveries attended by knowledgeable midwives. In contrast, the United States still lagged behind many other nations, including nations that emphasized the use of midwives, in several aspects of mother and newborn health.5
1 Susie, Debra Anne, In the Way of Our Grandmothers: A Cultural View of Twentieth-Century Midwifery in Florida, Athens, Georgia: University of Georgia Press, 1988.
2 Susie, 4.
3 Susie, 34.
4 Susie, 114-120.
5 Johnson, Kenneth C. and Betty-Anne Daviss, “Outcomes of planned home births with certified professional midwives: large prospective study in North America,” British Medical Journal, 2005; Kluger, Jeffrey, “Doctors Versus Midwives: The Birth Wars Rage On,” Time Magazine, May 16, 2009.