Revisiting an Ugly Past

A legacy of racism that led to the prohibition of the Grand Midwives and the rise of segregated midwifery programs persists via barriers to practice, including the DNP.

In this segregated program, midwifery students receive instruction on caring for a newborn. Photo: National Library of Medicine - National Institutes of Health

The ACNM 2018 Annual Meeting theme, Giving Voice to the Soul of Midwifery, celebrated and honored the Grand Midwives of the South. The Grand Midwives were descendants of enslaved older African women who provided comprehensive medical care to the enslaved population on the plantations during the period of enslavement. The plantation midwife honed her midwifery knowledge and skills via observation, apprentice training, personal experience, and oral tradition. After emancipation and reconstruction, the plantation midwife continued to be the primary source of health care in the community, giving rise to the Grand Midwives.

These midwives were respected and revered not only as elders, but also as central and integral figures within the homes of the families they served and the greater community. These women practiced their “craft” with a strong sense of spiritual calling, commitment, and honor for the traditions their foremothers had brought with them and the new ones they were forced to hone in unfamiliar spaces. They lived in the community, knew families intimately, were advocates, and were a source of comfort and support as they carried on the tradition of healing and offering birth rites and health care to families. These midwives contributed to reducing maternal and infant mortality and increasing access to health care for all. Black women would not have received any obstetrical care had it not been for the Grand Midwives. They were the originators of providing universal health care for the communities they served.

Eliminating the Grand Midwives

Many physicians, nurse-midwives, and nurses believed that the Grand Midwives placed women and infants at risk because they lacked formal education and engaged in unsanitary practices. This gave rise to racist rules and regulations during the early 20th century to address the “midwife problem.” The result was the development of local and state-run Grand Midwife training programs overseen by white public health nurses. Regulations enacted included the licensure and registration of Grand Midwives with individual states, which ultimately prohibited and restricted the Grand Midwives’ ability to practice and ultimately eliminated their existence. The destruction and elimination of the Grand Midwives gave rise to the trained and regulated nurse-midwives. The rise of schools of nurse-midwifery began in the 1920s and 1930s. These programs, however, were segregated. Nurse-midwifery education was not available to women of color until the establishment of the first formal educational program for the education of African American midwives, the Tuskegee School of Nurse-Midwifery (1941–1946). Tuskegee graduated 31 African American nurse-midwives who provided general health care to everyone in the community, became a liaison and resource between the community and local health departments, contributed to the reduction in maternal and infant morbidity and mortality rates, and educated future generations of African American midwives. Flint-Goodrich School of Nurse-Midwifery in New Orleans, Louisiana, was the second midwifery educational program to instruct African American midwives, opening in 1942. It closed in 1943. These African American midwives were not integrated, however, into the nascent nurse-midwifery community. The American Association of Nurse-Midwives, begun in 1928 by Mary Breckinridge, precluded membership by African American midwives.

Resurgence of Interest

The rise of the women’s movement in the 1960s and 1970s saw a resurgence in the interest of the utilization of nurse-midwives and a rejection of medicalized obstetrics. With increased demand for midwives came the proliferation of nurse-midwifery education programs. However, the number of students of color enrolled in ACME-accredited nurse-midwifery education programs was very small. By 1983, midwives of color represented approximately 6% of ACNM midwives. Today, midwives of color still represent approximately 6% of ACNM midwives. Yet, most of the women ACNM midwives serve are women of color.

ACNM has remained a predominately white organization. Until decades ago, the sole entry into nurse-midwifery was through nursing. Nursing, historically, has been a segregated profession. Student nurses of color, prior to Brown vs. Board of Education and the Civil Rights Act of 1964, could only access the nursing profession through diploma schools of nursing, such as Harlem Hospital School of Nursing and Lincoln Hospital School of Nursing, and the schools of nursing of historically black colleges and universities, such as Hampton University School of Nursing and Howard University School of Nursing. As a result, midwifery was and remains primarily white and middle class and, as such, ACME-accredited midwifery education programs have reflected and attracted that demographic.

Barriers to Entry

Over time, ACME-accredited midwifery education programs transitioned from certificate basic programs to masters’ degree programs. This change became problematic for prospective students of color. A survey of midwifery students of color in ACME-accredited midwifery education programs in 2015 indicated finances were the biggest barrier to midwifery education, followed by a lack of role models, mentors, and the support of family, midwifery education programs, and student colleagues. A survey of midwifery students of color indicated that finances were the biggest barrier to midwifery education.

A motion was introduced at the ACNM 2018 Annual Meeting in Savannah, Georgia, during the Business Meeting to call for a moratorium on the Doctor of Nursing Practice (DNP) degree as the entry to practice for midwifery. The motion did not pass. The rationale offered by opponents of the motion was that ACNM position statements exist, precluding the need for the motion. They are:

  • Mandatory Degree Requirements for Entry into Midwifery Practice ( “However, the Doctor of Nursing Practice (DNP) degree will not be a requirement for entry to practice for CNMs or CMs.” 2007; Updated 2015.
  • Midwifery Education and the Doctor of Nursing Practice (DNP) ( “The Doctor of Nursing Practice (DNP) may be one option for some nurse-midwifery programs but should not be a requirement for entry into midwifery practice.” 2007; Updated 2012.

Despite these position statements, some nurse-midwifery programs are transitioning from a masters’ degree to the DNP as the entry to midwifery practice. Initial consequences regarding this have been a decrease in the number of students of color entering these nurse midwifery education programs at the exact time that ACNM claims a commitment to increasing diversity, equity, and inclusion among its members and the midwifery workforce. Mandating the DNP degree as the entry into nurse-midwifery education by individual programs not only increases the length of time of study, it further increases the cost of the education when students of color have verbalized that finances are the primary barrier to midwifery education at the masters’ level.

Upholding the Tenets

Diversifying the midwifery workforce has been identified as a strategy to address provider race incongruence and the tragic maternal mortality statistics. We must guard against any educational strategy that further constructs barriers to that goal.

By Patricia O. Loftman, CNM, LM, MS, FACNM 
Board of Directors, Midwife of Color, Ex Officio


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