[HMD African American History Month Lecture:“Called To Practice"]

[LHC Auditorium February 25, 2010Not for Public Dissemination]

[Dr. Elizabeth Fee:] I'd like to welcome you to this celebration

of African American History Month.

You might have noticed that we've had

several celebrations. A couple of days ago very nice program, organized by Jill Newmark.

We have two exhibitions and about about one of them

more in a moment and now we have our African American

History Month Lecture by

presentation by Sheena Morrison. Now I'll introduce Sheena

for a minute or two.

She-- Sheena has an excellent training

both in history and public health.

She holds a Master's degree in history from Columbia University,

and she's currently finishing her dissertation in the history of public health and medicine,

also at Columbia University. Her master's in public health

comes from Hunter College, New York, where she specialized in

community health education. She then worked in the Office of the

Public Health Historian for four years,

where she was responsible for archival

research for running an oral history program. And for assisting researchers want both

inside and outside the Public Health

Service who wanted to do research.

Now, sadly, that office is now defunct.

So Sheena worked for a while as a

contractor for the History of Medicine

Division and did a terrific job for us.

She, among other things, has worked on an exhibition,

and the exhibition is currently just outside

and inside the history of Medicine Division. It's called Nothing to Work With

but Cleanliness:  African American Grannies,

Midwives and Health Reform.

So I hope if you haven't seen it yet, you will come and see it.

And today's lecture is on a similar a project,

Called to practice: African American "grannies",

midwives, & health reform.

Let me take just a moment to tell you about

the next Women's History Month lecture.

It'll be on 25th of March and the the topic is:

Reproductive Technologies and the Post Human Future.

Are we there yet? It's by Professor Valerie Hartouni of the

University of California at San Diego. And it's here in the Lister Hill Auditorium,

also at 2 o'clock. Now, if you would please join me

in welcoming Sheena Morrison.

[Applause]

Oh, there's one thing I didn't neglected to tell you about Sheena,

and she is the H1N1 historian.

She is situated both in the National

National Library of Medicine and also in

the Office of Preparedness and Response. So she has two mentors,

supervisors, one in each place, and she travels back and forth.

And is doing a wonderful job for that office of recording history as it's happening.

[Sheena Morrison:] Thank you Liz. Good afternoon.

[Presenter preparation]

[Called to practice: African American"grannies", midwives, & health reform]

Prior to the 1920s, most African American midwives in the South became midwives

either by apprenticeship, usually with the familial relation

or because they believe they were called to do so by God. After the 1920s,

the only way to become a midwife was through recruitment to one of the

state sponsored midwifery training programs by a public health nurse.

The programs were intended to improve

maternal and infant care in the rural South and range from the minimum basic

instruction to expansive preparation. From simply providing midwife permits and

birth registration to more structured training in the form of annual midwife

institute and monthly club meetings. Training programs for midwives in the

United States were only meant to be a temporary solution to meet the needs

for maternal and child healthcare services in areas where hospitals

and physician services were scarce. But in the South, racial segregation and a weak Southern

economy sustained the social conditions which expanded the role of midwifery and maternal and care,

even as reformers sought to eliminate the practice of midwifery. As a result,

midwifery persisted in the South for more than five decades

beyond the campaign to eliminate midwives. The material for this talk is drawn

mainly from the National Library of Medicine's American College of Nurse Midwives collection and is

based on an exhibit that I created, which is now on display outside the History of

of Medicine reading room here at the library. Called to Practice is just one of many narratives about

granny midwives that can be culled from the material in the collection.

The focus of my talk will be on the state and local training programs

designed to educate the granny in the rural South from the 1920s through the 1960s.

I will begin with an overview of the context in which training programs for midwives first emerged.

Followed by a description of the two primary modes of instruction,

clubs and institutes that were used to teach African American midwives in the South.

To conclude, I will show 4 short clips of the film All My Babies. The film was commissioned by the

Georgia Department of Public Health and directed by George C Stoney in 1952

to educate local midwives. The clips I have chosen illustrate key concepts

taught in midwife training programs throughout the South.

For over 3 centuries, African American midwives delivered

babies and practice folk medicine in rural counties throughout the South.

Without any formal training but with a good deal of practical experience,

the granny midwife treated pregnant women, their families, and other members of her community.

And freedom as in slavery, African American midwives worked under the most difficult conditions.

There was little improvement in the overall standard of living for most African Americans in the

decades following the Civil War. Black families in rural South and

the rural South still lacked clean water, adequate housing, and nutrition. As a result,

many of the communities were beset by endemic and epidemic disease. Midwives were one of the many

different kinds of healers. Their residents, black and white, relied upon for care and treatment

when they became ill, and they were held in high esteem.

The practice of midwifery came under

public scrutiny during the 1910s, when progressive reformers collected birth and death--

death statistics that show mortality among women and infants in the United

States was significantly higher than in some Western European countries.

American physicians and public health officials tended to attribute the higher

death rates to the unsanitary practices and superstitious beliefs of midwives.

Some reformers advocated for midwives to receive formal training, but most argued that the better

solution would be to replace midwives with physicians altogether. During the next two decades,

reformers campaign unsuccessfully to eliminate the practice of midwifery.

Resolutions to the midwife problem were frequently the subject of

discussion at annual meetings held by professional organizations with an

interest in maternal and child health. But some of the social and economic

barriers to eliminating midwives were not so easily overcome. In Northeastern cities,

midwives have been largely displaced by physicians working in hospitals.

Many women considered hospital births the modern and advanced form of delivery.

But midwifery persisted in southern rural communities, where the majority of African American

midwives practiced. During this period there was simply not enough skilled

physicians or hospital facilities in southern rural communities to replace

the services provided by midwives. African American midwives were

responsible for the delivery of over 50% of all black infants in the

South and 25% of infants nationwide. Moreover, most physicians, white and black,

were unwilling or unable to accept the

meager fees midwives were willing to accept. Often,

midwives would accept livestock as payment

or be forced to receive nothing at all.

In an era of pervasive racial discrimination, few black families had access to or could

afford the cost of hospital deliveries. Poverty and discrimination also made

home births more desirable than hospital deliveries to many African American

women living in the rural South. As a result of these barriers,

training for African American midwives was deemed the most viable solution.

Reformers proposed that granting midwives be trained by public health nurses, certified in midwifery,

and regulated through the state and local health departments.

There were no legal precedents for the care of maternity in the United States prior to the 1920s.

In 1921, Congress passed

the Sheppard-Towner Maternity and Infancy Protection Act, the first piece of of legislation

to address maternal and child health in the United States. The bill, which was administered

by the Children's Bureau, was enacted by a coalition of reformers and public health officials

concerned about the large number of deaths among women and children.

The Sheppard-Towner Act was intended to address some of the commercial, I'm sorry, some,

of the economical barriers to healthcare for mothers and and infants.

Supporters of the bill had hoped that it would lead to universally available maternity care,

but their vision of publicly funded medical and nursing care for every woman was lost in 1927 when

a coalition of medical societies and conservative organizations. Charged that it was a step towards

state medicine and fought efforts to renew it. From 1921 to 1929,

the Sheppard-Towner Act provided matching funds to states for midwife education.

Midwife training programs were only meant to be a small part of the overall

purpose of the act and Southern states, however, instructional programs for midwives

made-up a significant portion. Southern states with large numbers of midwives have and a shortage of

physicians and hospitals invested heavily in regulatory and training programs.

The midwife programs established under the Sheppard-Towner Act were modeled on the pioneering

work of doctor S Josephine Baker, the director of New York City's Bureau of Child Hygiene,

who was closely affiliated with the Children's Bureau. Baker was among the group of reformers

who saw midwives as a necessary part of the healthcare system and argued

in popular and medical journals that death rates for midwife attended

births were not higher than hospital deliveries attended by physicians.

Others, like doctor Joseph B DeLee, known also as the father of obstetrics,

argued against the midwife having any role in maternal and child healthcare. In his own words,

he was fundamentally opposed to any movement designed to perpetuate the midwife.

Regardless of their stance on midwifery, private practitioners and public

health officials all agree that midwives could not continue to deliver babies without the benefits

of scientific medical knowledge.

As part of the overarching goal to modernize childbirth practices in the South

granny midwives were required to register with health departments to obtain a permit and to attend

a prescribed course of study. The venue for instruction was usually the monthly midwife club

and the annual institute. Some states had literacy requirements and required midwives to undergo an

annual physical examination to remain in compliance with state regulations.

Early state efforts to monitor midwives first began with the campaign to locate

and register all practicing midwives. Registered midwives were then mandated

to attend monthly midwife meetings, usually held in local health

departments or churches. A nurse midwife, charged with

statewide supervision of the midwives, traveled to the different counties, providing a series of

lectures on cleanliness, equipment and birth registration.

To ensure that the women maintain sanitary standards beyond the monthly midwife meeting, a nurse,

midwife or public health nurse also visited the homes of the midwives and sometimes

accompanied them on deliveries. Midwife clubs were initially organized to

regulate midwives and serve as a venue of support for small groups of women.

There is some evidence that the concept of midwife clubs first served as a measure

of control in counties where there wasn't an organized health department.

Little in the way of instruction was accomplished early on. The monthly meeting served primarily as

a means for the local health officer to keep track of the register midwives.

They later evolved into sessions where, in addition to some instruction,

midwives could replenish their supplies. During the mid during the meetings,

midwives could buy the supplies at cost from the nurses. But even at cost,

keeping the bags stocked according to regulations sometimes proved to be

a hardship for many of the midwives who were barely making a living from their practice.

The replenishment of supplies also provided a concrete reason for the

monthly meeting and was a good segue into the bag inspection.

The midwives bag was inspected for cleanliness and content by an assigned

group leader or the public health nurse. Midwife bags often contain herbal remedies,

patent medicines, and in some cases, drugs provided by local physicians.

After the Sheppard-Towner Act, they were prohibited from carrying any item

not approved of by the Board of Health. Whereas clubs tended to be more

means of regulating midwives, training was the primary focus of the annual state sponsored institute.

There was more planning involved, and a typical two week institute drew women

from all over their respective states. These were generally held on the

grounds of black colleges or normal schools with overnight accommodations for large groups of women,

and midwives were responsible for paying for their own room and board.

Instruction was carried out through demonstration, role-playing and songs.

Because most midwives had little formal education and many were illiterate.

During midwife training institutes, a nurse midwife or public health nurse

presented the lessons and demonstrations, and she would be assisted by a group

leader chosen from among the midwives. Miss Chase, an anatomically correct life sized doll,

in the 10th month of pregnancy. Was used for lecture and demonstration

during midwife training sessions. Special lectures were also given

by doctors and nurse consultants. Each midwife was then evaluated on her

ability to repeat the demonstration, for example on how to prepare a model

birth room or the proper technique for cutting the umbilical cord. The class curriculum included

principles on pre and postnatal care an what complications midwives might expect.

Role-playing was used to evaluate the midwives understanding of the lesson,

as well as to prepare her for

unexpected or difficult situations.

Songs were often used to convey the significance of of many of the concepts.

Like birth registration for example, or why sterilization of equipment was necessary.

The lyrics to a song written by one of the nurse midwives explain many of the benefits

[Silence]

of birth of having a birth certificate throughout one's life cycle, from school registration

to Social Security benefits. For the smaller institutes, county health departments,

churches, and African American schools were used as venues. There were even institutes that

provided on the job training. Like the one held in Denmark County,

South Carolina from 1926 to 1929.

It was held at an African American school affiliated with a small hospital.

The classes were held continually for three months during the summer and

each midwife attended for one month. Classes were held in a clinic like fashion and the and the

midwife performed all the work, including the deliveries. The Denmark County Institute was

a unique situation, however. During institutes, midwives characteristically demonstrated

their competency without the benefit of real patients. And both venues, however,

the midwives professional obligation to her patients mother and child was emphasized throughout the

event and permits were renewed upon the successful completion

of the Training Institute. The practical application of lessons

taught during the annual institutes and reinforced during the monthly clubs

were not always possible however. Conditions under which midwives

practice in the field were often not sterile. Most homes were without adequate lighting,

heat, proper ventilation or running water, and expectant mothers were unaware

of the sterile birth techniques that they would later come to expect.

[Portions of lecture are missingdue to faulty original disc]