Looking Back to Find Our Way Forward
- Angie Chisholm
- 11 minutes ago
- 5 min read
In honor of Black History Month, it is worth asking a difficult but necessary question: What would maternal health in Kentucky look like today if we had built a maternity care system that honored the legacy of Black and community-based midwives who once formed the backbone of care across our state?
To understand the current state of midwifery and perinatal care in Kentucky, we must begin with our history, both local and global.
Midwifery Before Medicine: A Respected Community Profession
Worldwide, midwifery is one of the oldest professions. In many countries, midwifery has remained an uninterrupted, community-centered model of care, especially for pregnancy and birth. In the United States, however, a sharp divide emerged between midwifery and medicine.
Before the rise of formal medical education, midwives were the primary, and often only, experts on birth. They were trusted, highly skilled, and embedded within the communities they served. Birth was not considered a medical event but a social and cultural one, supported by women who carried generational knowledge.
That began to change in the early 20th century. As physician-led obstetrics expanded, legislation such as the Sheppard–Towner Maternity and Infancy Protection Act of 1921 introduced new regulations that restricted midwifery practice. At the same time, organized medicine launched coordinated propaganda campaigns portraying midwives as “incompetent,” “unclean,” “witches,” and “untrustworthy.”
Through a modern historical lens, it is clear these narratives were rooted in racist, sexist, and classist beliefs. They disproportionately targeted apprentice-trained midwives–many of whom were Black women, immigrants, or rural caregivers—and framed community knowledge as inferior to academic medicine.
Kentucky’s Distinct Midwifery Legacy
Kentucky’s story both reflects and resists these national trends.
Long before European settlement, Indigenous communities in the region relied on midwives to support pregnancy and birth. As settlers arrived in the 18th and 19th centuries, midwives remained central to reproductive care across the state.
By the 1920s, while urban white populations across the U.S. increasingly turned to hospital births, midwifery persisted in much of Kentucky, especially in rural and Appalachian regions. A 1922 survey of childbirth practices in eastern Kentucky found that midwives attended 85% of births and outnumbered physicians 14 to 1.
In Appalachia, “Granny Women” lived in and served their own isolated mountain communities. In both rural and urban Kentucky, Black midwives, often called “Granny” or “Grand” midwives, continued attending births well into the 1940s. These midwives were apprentice-trained, knowledgeable about birth physiology, herbal medicine, and community care, and often provided services far beyond childbirth.
According to a Bureau of Maternal and Child Health survey, an estimated 2,245 registered midwives were practicing in Kentucky in 1925, though this number likely undercounts those in remote areas. Between 10–30% were African American. For comparison, Kentucky today has around 100 practicing midwives and approximately 475 OB/GYNs, which represents a striking decline in the Kentucky perinatal care workforce.
Kentucky is home to Frontier Nursing University (FNU), founded in 1925 by Mary Breckinridge as the Frontier Nursing Service (FNS). FNS brought organized midwifery and public health nursing to rural Appalachia and laid the foundation for modern nurse-midwifery education in the United States. In 1939, Breckinridge established the first formal graduate training program for nurse-midwives, seeking to standardize education and secure legitimacy for midwifery within an increasingly physician-dominated system.
Honest reflection requires us to recognize that Mary Breckinridge held racist beliefs consistent with the segregationist structures of her time. Black midwives were not envisioned as part of the emerging professional model, and early Frontier services were not equitably accessible to Black Kentuckians. Acknowledging this history does not diminish the clinical advances of Frontier’s work, but it allows us to more fully understand how racial exclusion shaped the profession and why intentional inclusion is necessary today.
Today, FNU graduates approximately 40% of the nation’s nurse-midwives, with 34% of students identifying as students of color. Frontier, now located in Versailles, Kentucky, remains one of the most influential institutions shaping the profession.
As midwifery education moved into academic institutions, apprentice-trained midwives (many of whom were Black) were systematically marginalized through regulation, credentialing requirements, and professional gatekeeping. This professionalization of midwifery contributed to the displacement of a robust Black midwifery workforce. That legacy continues to shape who has access to training, licensure, mentorship, and leadership today. Additionally, this helps explain why our current workforce does not reflect the diversity of the communities we serve.
Current Impact
Kentucky currently faces a maternal health crisis. Large regions of our state lack access to pregnancy and birth providers altogether. More than half of Kentucky counties have no practicing midwives, and some have no obstetric providers of any kind. Outcomes for Black birthing people remain disproportionately poor.
These realities are not accidental. They are the direct result of policy decisions. As we envision the future of midwifery in Kentucky, we must look to our past and honor the legacy of the Black and rural midwives who once sustained our state.
This history is neither abstract nor anonymous. Through archival records recently published by Reinette F. Jones at the University of Kentucky, we are able to name many of the Black midwives who practiced across Kentucky in the late 19th and early 20th centuries. The legacy of midwives like Lula Green in Bell County, Sara Duncan Watts in Breckinridge County, Josie Black in Fulton County, and many others featured in this database, reflects the reach of community-based midwifery in Kentucky’s past. Bringing this history forward helps us better understand how today’s workforce shortages came to be.
Questions for the Future
If we are serious about improving outcomes and access, we must ask:
How do we rapidly and ethically grow a diverse midwifery workforce in a state where provider shortages are severe and worsening?
Can we reconcile Mary Breckinridge’s vision of standardized, evidence-based training with pathways that are accessible to people who want to serve their own communities?
Could establishing midwifery programs at Kentucky’s HBCUs (Kentucky State University and Simmons College) be part of the solution?
What would it look like to build an infrastructure that truly integrates midwifery with seamless access to higher levels of care when needed?
Honoring Black History Month is not just about remembrance. Kentucky’s midwifery future depends on us to learn from the past, work on restoring what was lost, and create systems that value community knowledge, cultural continuity, and equitable access to care.
The path forward has already been walked. We just need the courage to follow it again.
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