Delivered by Midwives: African American Midwifery in the Twentieth-Century South by Jenny M. Luke (review)

Jenny M. Luke has written a concise book that raises a myriad of complex themes: sexism, professional identity and authority, classism, state and federal struggles over the definitions and funding of health care, and, most significant, racism in all its persistent forms. The book details the ways these mammoth struggles defined the experiences of African American midwives.

Luke begins her narrative by introducing a construction, borrowed from biobehavioral health specialist Collins Airhihenbuwa, that “takes into consideration micro and macro factors of care” (p. 6). “[M]icro elements of health,” according to this model, are “those found at the grassroots level,” while “[m]acro-level health care brings with it state and federal structures and the associated hierarchy, the potential for racism, and the presumed superiority of Western modern medicine” (p. 6). Luke refers to these distinctions between micro- and macro-level institutions and experiences frequently, essentially establishing a narrative in which lay midwives were brought under the control of practitioners of scientific medicine and regulated until they were no longer economically useful; they were then outlawed by state legislators guided by medical practitioners. Her story, then, is of the triumph of the macro over the micro.

The great challenge is that neither the micro nor the macro was ever static or monolithic. As has been well documented, enslaved peoples shaped, to their fullest ability, the experience of captivity and forced labor. Nowhere was that truer than in the area of reproduction, as Luke acknowledges in her early chapters. The agency that lay midwives asserted on the plantations and during Reconstruction was profoundly challenged, however, when they encountered scientifically educated physicians and their allies in state governments.

Luke reminds readers that the forces arrayed in support of introducing scientific advances into childbirth were diverse and varied. African American physicians, usually men, struggled to secure adequate education, residencies, and hospital privileges before the 1960s. Nurses of all races faced resistance in achieving formal education and professional status. State governments were hampered by inadequate budgets and little political will to commit to their African American citizens. When federal dollars arrived in the 1920s through programs like the Sheppard-Towner Maternity and Infancy Act (1921), physicians and reactive politicians screamed “socialized medicine” and undermined programs as often as they implemented them. Racism ran through all of these efforts, as the author acknowledges.

Midwives were victimized by this mind-set while their continued practice contributed to its perpetuation. So long as racism limited efforts to secure medical education for African American physicians and nurses, and the chronic poverty of rural southern African Americans made them an undesirable patient pool for white doctors, then there was tolerance for state-sanctioned lay midwives. By the 1970s, that all changed. Physicians found new economic opportunity in obstetrics, especially if their patients possessed private health insurance. At the same time, nurse-midwives, who have always been predominantly white, sought a monopoly as the only legitimate nonphysician childbirth attendants. Luke documents the creation of a two-tiered system in many parts of the South in which less affluent women were attended by nurse-midwives and privately insured women saw physicians.

Luke asserts “that the juggernaut of scientific hegemony forced into obsolescence a brand of care that held intrinsic value” (p. 145). This author helps readers see how scientific medicine was integrated into lay midwifery but demonstrates that this sharing of knowledge and skills was opportunistic. Scientifically educated doctors and their government and professional allies did not recognize the “intrinsic value” of lay midwifery, sacrificing traditional practice on the altar of science.