Why midwifery isn’t being taught at America’s Black colleges

American midwifery is too small, and too white.
American midwifery is too small, and too white.
Image: Reuters/Callaghan O'Hare
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Midwifery in the US is on the rise.

After being relegated to the sidelines of childbirth for many decades, midwives are gaining some recognition in the US. That’s in part thanks to an effort to tackle the over-medicalization of childbirth, to help address the crisis of maternal mortality, as well as provide a more robust workforce in areas with shortages of specialists. 

The number of students enrolled in midwifery programs in US universities has climbed more than 20% since 2015, and the number of midwives has more than doubled since 2010. But one significant subset of US higher education is missing: historically Black colleges and universities (HCBU).

The US midwifery workforce isn’t just small, but very homogenous. Over 90% of the 12,000 midwives in the US today are white, and less than 700 are Black, says Michelle Drew, a midwife and the director of Ubuntu, a collective of healthcare and community workers serving Black families in Delaware.

This is especially concerning because Black women have four times the risk of maternal mortality than white ones in the US, where the rate of pregnancy-related deaths is the highest in any rich country. Having more Black midwives could encourage Black women to seek their services, leading to safer births. Further, research has shown Black healthcare providers are associated with better health outcomes for Black patients.

The value of midwives

Midwives are healthcare professionals—typically, but not always, nurses—trained to assist women during pregnancy and childbirth. They are not doctors, so they cannot perform emergency medical interventions, such as C-sections, but can otherwise replace an obstetrician in an uncomplicated delivery.

There are many sound reasons for promoting births with midwives. They can typically spend more time working with the mother ahead of delivery, and since they are trained differently from doctors, they are less likely to opt for unnecessary—and at times risky—medical interventions, such as medically inducing labor.

Research has found midwives are associated with safer birth outcomes,  and several programs and policy interventions—such as the recent bipartisan Midwives for MOMS Act, introduced in Congress in May this year—have been seeking to grow and diversify the midwifery workforce.

Yet even with this progress, the US trails comparable countries in its per capita number of midwives. In the US, only 8% of deliveries are assisted by a midwife. By comparison, across Europe, more than 75% are, with as many as 80% in Germany, 90% in the Netherlands, and 98% in France. For every 1,000 live births, countries such as Australia or Sweden employ nearly 70 midwives; the US employs four.

A legacy of discrimination

The story of how the American midwifery force got so small, and so white, begins 100 years ago, with the Sheppard-Towner Act of 1921, a piece of legislation promoting maternal and child health. Among the provisions of the act was the regulation of midwives, who until then assisted about half the births across the country. Overall, about 90% of Black children were delivered by community-based midwives, says Drew, who has done extensive research in the history of midwifery in the Black community.

Although the main culprit of infant mortality was syphilis (penicillin wouldn’t be introduced for another two decades), the lack of formal training of midwives, who were typically Black women, was singled out as the cause by the architects of the legislation.

At the time the act was passed, the medical establishment was actively working to discredit midwives. Since the early 20th century, obstetricians and gynecologists had worked to establish their discipline in the US by framing pregnancy as a disease, and pitching themselves as the doctors to cure it. Professional medical organizations likened midwifery to little more than witchcraft, encouraging women to rely on medical intervention for deliveries, with the goal of exploiting the market potential of childbirth.

To professionalize midwifery—as well as make it harder to get into—Sheppard-Towner introduced a requirement that midwives attend nursing and public health training prior to formal midwifery education.

In less than a decade after the passing of the act, the percentage of births attended by midwives fell by 15%, and it was primarily in the segregated South that community-based midwives continued to deliver African American babies, albeit without the official training now required by law.

Getting an education in midwifery wasn’t easy for those who wanted it, either. Until the 1940s, only four institutions provided recognized training for nurses to become midwives: the Manhattan School of Midwifery, the Flint-Goodridge School of Nurse-Midwifery in Kentucky, the Catholic Maternity Institute in New Mexico, and the Tuskegee School of Nurse-Midwifery, in Alabama.

With the exception of the latter, which was opened at the Tuskegee University, a HBCU in 1941, all other programs were either officially or de-facto off-limits for Black students. (Prior to Tuskegee’s program, in 1932, Dillard University, an HBCU in Louisiana, opened a midwifery program that never made it past the first year due to lack of funding.)

In the years that followed, the midwifery workforce continued to dwindle, and the profession continued to be discredited by the obstetric establishment in all demographics. But the limited access Black students had to midwifery training all but erased their representation in a field that was once a linchpin of the community. And, with the absence of Black midwives, Black communities became even less likely to avail themselves of midwife services.

How to bring midwifery to HBCUs

The Tuskegee School of Nurse-Midwifery eventually closed in 1945, and while at least two programs provided training at HCBUs over the years, the last was discontinued in 2007.

No other HBCUs have been able to set up training for midwives since, and the reasons for this struggle ‘are primarily financial. Midwifery programs are expensive to offer, because they need to offer clinical training, and the insurance coverage necessary to work in childbirth is costly.

HBCUs often have much smaller endowments than other institutions, and many have been chronically underfunded, leaving them lacking resources to establish a costly midwifery program, even when they already have departments of nursing or medicine, as 39 of them do.

Since 60% of the faculty of HBCUs, and the majority of students, are Black, providing specific funding to set up midwifery programs in them would have a sizable effect in increasing representation in the profession.  That, in turn could help Black communities regain familiarity with the role of a midwife, and not think of it as an extravagant childbirth novelty for the white elite, says Drew.

But HBCUs don’t just need money to set up the midwifery programs, they need the support of institutions that already host them. Beyond the financial resources required, setting up degrees in midwifery is complex and takes time. “If you’re going to start a new program, it will usually take between two and five years to get through all the administrative channels in your own institution,” says Monica McLemore, a professor of family health nursing at the University of California in San Francisco.

Once the program is approved within the institution, and a first class of students has graduated, it can apply for approval from the Accreditation Commission for Midwifery Education, so that its graduates can be admitted to licensing exams. It’s a big risk to take, setting up a program and getting students through it before even getting accreditation.

A little help from non-HCBUs friends

To speed this up, McLemore proposes a solution: partnerships. Institutions with established midwifery programs would work with HBCUs, offering them support in the design and evaluation of their programs, so that once they are ready for review the accreditation is speedier.

But more substantially,  McLemore thinks existing programs should offer a bridge for HBCUs students interested in pursuing midwifery while the programs are set-up in their own institutions. In practice, says McLemore, students at HBCUs would attend classes according to the program of another institution with a midwifery program in the area, and then once the program is set up in their home university, would resume their studies there. Since the new midwifery curriculum would be set up with the support of the existing one, the transition would essentially be automatic and nor result in any loss of credits for the students.

“I have submitted [grant proposals] for the last five years trying to create linkages between historically black colleges and universities and universities like mine,” says McLemore. “Why can’t we make that process easier so that if we were in partnership, the students could start in our program and finish in the new program?”

Unfortunately, getting funding remains difficult. Even well-financed universities don’t have the resources to finance many new programs, so the proposals in this field are often competing with others that might be given the priority. Government funding for midwifery education, too, has to cover a lot of grounds—and since none is specifically earmarked for HBCUs, it tends to go to programs in areas that already have midwifery colleges.

But McLemore sees potential hope in private philanthropy. McKenzie Scott’s recent gifts to HCBUs and Native America colleges—ranging from $20 million to $50 million—turned the attention of donors towards the key role of these otherwise overlooked institutions. This new focus, alongside the actual resources made available through the gifts, could help, though without the partnership of established institutions, the path might remain too difficult for any HBCUs to risk substantial funding for it.