ARTICLES & ESSAYS
Waiting for Babies: Lay Midwives in Louisiana
By Maida Owens
Until recently, lay midwives were the traditional birth attendants in most Louisiana communities. This traditional folk occupation was demanding, but rewarded the practitioner with self-satisfaction and respect from the community for what most considered a God-given talent. Lay midwives attended women in their own communities, seldom working under the direct supervision of a physician. Training of lay midwives varied greatly, from apprenticeship to formalized nursing training. Nevertheless, lay midwives agreed in their perception of their role in the birth of a baby. Lay midwives differed from physicians in that they "waited" for a baby's birth rather than "delivered" the child. Thus, they adopted the role of non-interventionists: assisting natural developments of the birthing process rather than controlling it. As one midwife succinctly put it, "You do not make the course that a baby will go, you follow it" (Sarah 1985).
This paper will analyze the traditional practice of midwifery in Louisiana, its decline and re-emergence among a new group of women. Despite organized efforts to eliminate this folk occupation, lay midwifery persists in the face of modernization. Apparently, this cultural role fulfills a need in society and in the lives of the women who pursue it.
Louisiana's tradition of midwifery differs from other parts of the United States in several ways. Louisiana midwives practiced among most ethnic groups, among both native and foreign born, and in both urban and rural settings. If reports from other Southern states prove to be accurate, midwifery was primarily an African-American rural tradition, except in Appalachia where it was an Anglo tradition and in southern Texas where Hispanics dominated. Northern cities report that it was an urban phenomenon dominated by the foreign born (Doughtery 1982, Holmes 1984, Litoff 1978, Mongeau 1961, Osgood 1966, Schreiber 1978).
Midwives crossed the spectrum of ethnic groups in Louisiana. North Louisiana resembles other areas of the South in that midwives were primarily English-speaking African Americans although one might find a smattering of white Anglo women so employed. South Louisiana, though, was noted for its French speaking Cajun and black Creole practitioners. In addition, several Indian tribes--Chitimacha, Koasati (Coushatta), and Choctaw bands--relate a midwifery tradition being prevalent well before the 1930s. Until the 1950s, the Houma Indians residing in the marshes, sustained their own midwife who traveled to deliveries by boat. Italians, settling in urban and rural Louisiana well before the turn of the century, are noted as having brought midwives with them. Clearly, midwifery was an acceptable manner of birth/delivery care for many ethnic groups within the state.
In contrast to other large Southern cities, Louisiana urban areas also had strong traditions of midwifery. In fact, New Orleans proved particularly strong, with 85% of the births in 1915 employing them, at a time when the national average amounted to 29.8% (Watson 1921). Approximately 300 registered midwives practiced in the parish of Orleans. The city directory listed 18 to 142 of them between 1879 and 1950 with French, Anglo, Italian and German surnames. The Yellow Pages listed 8 to 15 midwives annually between 1910 and 1963.
Often the term "granny midwife" is applied in describing the lay midwife. In Louisiana, however, midwives did not refer to themselves as that, nor for that matter did their clients. Instead, the term here seems to be one of a descriptive nature used by professionals and the elite, apparently emphasizing that the midwife possessed little formal training. Perhaps the term arrived here by way of Appalachia, where the term has been applied to lay midwives by both themselves and their clients. Professionals and the elite who are more oriented to the method of training, are more likely to use the term "granny midwife" in Louisiana. Lay midwives are apt to judge the performance skills of the individual rather than her training. French, the dominant language of South Louisiana, has several phrases referring to midwives (Daigle 1984). La sage femme,, for "wise woman," is one that is often seen as a reference to midwives, and appears to be correlated to one who deserved considerable respect in the community. Another, la vieille femme, or "old woman," denoted the tendency to older age among midwives. Chasse femme, in this case meaning "to expel," was popular as was accoucheuse, or "one who delivers." In most cases, such pseudonyms effectively indicated the performance expected from the midwife, regardless of how they obtained their skills.
Midwifery is often viewed as an indicator of poverty--both for the client and the practitioner. This seems true in Louisiana; nevertheless, a midwife needed a stable economic base to support a practice. She tended to have few familial responsibilities; i.e., a widow or an elderly woman, or one with a family that could afford her absence during the birth process. A practitioner might be away from her household duties as much as three days, not being able to care for children, work the garden, or perform other sundry chores around the home. Payment for services might be in the form of quilts, chickens, or a tub of greens. In the past, the state paid them twenty-five cents for registering a birth, little monetary reward for such services.
Midwifery often involved a personal struggle, with many relating their husband's reluctance to accept their practice. Some reported the need to abandon the practice for a number of years, particularly when they had younger children. Since midwifery often led to family problems, one wonders why they continued to be drawn into the practice. One commonly expressed theme is that God had called them to such a special service, and this carried an obligation to utilize that "gift." Frequently, the community had actual need for more midwives, and this prompted their response to their neighbors. The challenge of assisting births and the accompanying self-satisfaction was also an important motivation for these women.
A good midwife had to cope with whatever situation confronted her. And while, more often than not, the birth might be unattended by any serious problems, the midwife had to be able to perform should anything occur until medical help could be summoned. In this role, many women found a socially acceptable manner of expressing freedom and independence unobtainable by other women. They might keep irregular hours and have access to virtually any home in the community. Such status and prerogative might often only be accorded to a highly respected community member, such as the church minister.
Midwives had geographical limitations to their practice due to transportation restrictions and the high-value placed upon convenience by clients. Frequently, several midwives shared an area with little competition for clients since demand was high for the few available practicing midwives. Both black and white midwives practiced in most Louisiana communities. Interestingly, such practitioners seldom encountered difficulties along racial or ethnic lines, this fact being significant since ethnic stratification permeated other social institutions within the community. Taboos or inhibitions against white midwives attending African-American clients or vice versa occurred infrequently, although preference for a midwife of one's own ethnicity was exhibited when one was available.
Physicians practiced in many portions of the state since the early 1900s and gradually expanded their practice into obstetrics; however, time constraints precluded their being available to everyone for attending child birth. As a result, midwives may be found practicing their trade with the cooperation of the local physicians. Clientele tended to be divided between physicians and midwives along ethnic or economic lines. Physicians generally limited charity cases to those with life threatening complications during delivery; midwives, however, served regardless of the family's ability to pay.
Clients, on the other hand, had reasons other than economic ones for preferring to utilize the midwife. Usually, the client could rely upon a greater degree of personal attention and more involvement in decision making concerning the birth. Attended by a midwife, the birth remained primarily the client's experience simply assisted by the midwife. Convenience also played a part in the choice of attendants. Usually, a mother did not have to plan for placing her children in other's care until delivery, or at least not experience an extended separation. More often than not, the midwife visited the client's home prior to birth, often to assist in setting up a nursery or to provide other needed advice. Ideally, the practitioner would have been contacted early enough to encourage the pregnant woman to seek diagnostic evaluation of the fetus in order to avoid complications. Often this included going with the client to the maternity clinic, operated by the parish health unit, as support for her. At the onset of labor, the midwife then went to the client's home, prepared to stay for as little as a few hours, or perhaps as long as several days. Most returned to visit the patient after delivery, often on a day-to-day basis. In some parishes, this was augmented by a public health nurse notified of the birth by the midwife. Frequently, the practitioner continued to maintain contact following delivery for an appreciable length of time, urging the mother to visit the health clinic for the six-week check-up. Such personal attention and support customarily did not come from the local physician or hospital due to heavier patient loads and time demands. Women had yet other reasons to prefer midwives rather than physicians. Some women expressed discomfort over physical examinations, particularly when administered by male physicians. Midwives, in addition to being of the same sex, frequently did not perform pelvic exams and were sought out for just that reason. One woman related that she had succumbed to family pressure to be attended by the local physician. She kept the appointment, but panicked and ran out when summoned to the examining room. Additionally, some women could not be attended by physicians without risking legal repercussion. One midwife reported that she regularly attended illegal aliens working as migrant field workers brought to her by a local foreman. For many women, no realistic alternative existed other than a midwife. Financial constraints precluded any other services.
Traditionally trained by informal apprenticeship, midwives frequently considered their midwifery skills as a gift from God and felt a profound responsibility to pass their skills to an apprentice. Ideally, the young woman who had shown interest in midwifery would pursue this calling after her childbearing years. Whereas the average child would likely be ignorant of sexual or childbearing facts, the young girl in a family with a midwifery tradition may have been permitted to be more curious, and this interest was nurtured from a young age. During her own childbearing years, she would informally assist a midwife, attending births when convenient, and acting as an aide. This informal educational process met no specific timetables or rigid guidelines, and the woman proceeded at variable rates that allowed for the demands of a woman's family and her fluctuating interest. Years might pass during which the midwife and apprentice's relations intensified, with the apprentice gradually assuming more responsibility during births. Eventually a situation would arise, such as concurrent births, necessitating the new midwife to assume complete responsibility. Even though the apprentice gradually broke away from the midwife and established her own practice, close ties remained. The apprentice freely sought advice when facing new situations. This ideal pattern of training by apprenticeship frequently was not followed. Some midwives, considered lay midwives based on their style of practice, often had more formal training than one might suspect. Therefore, a clear division, such as one might assume between the folk or lay midwives and the nurses or certified nurse midwives did not exist. The following descriptions of two midwives illustrate the wide range of training, attitudes, and practice styles found among lay midwives.
Sarah, an African American woman born in 1899 in a central Louisiana parish, is intensely dedicated; her religious calling permeates her life as well as her practice (Sarah 1985). Midwifery had been a family tradition, traceable to her grandmother's practice, but Sarah did not benefit directly since her grandmother had died prior to Sarah's birth. Sarah related the story of her first interest in midwifery. At age eight, her mother discovered Sarah playing with dolls as if they were in labor and having difficulty with the placenta. Her mother, quite upset, wondered where her daughter had gotten this interest. Sarah insisted, then and now, that she had dreamed it. Worldwide, midwives frequently report a mystical experience, including dreams, as a basis for their recruitment to this cultural role. Sarah's interest in birthing and babies continued. At age sixteen, she attended nursing school at a Little Rock hospital. After spending the majority of her practical experience in the maternity wards, she returned home after two years to begin her midwifery practice. Subsequently, Sarah attended Grambling University, becoming a teacher. Sarah taught during the day and birthed babies at night in addition to having a family of four of her own and eight adopted children. Talking to Sarah about her midwifery practice, one is impressed by the fact that she routinely handled births that today are considered difficult, such as twins, breech or other presentations. Seldom seeking a doctor's assistance, she relied on prayer to guide her in handling a birth as do midwives in most other cultures. Sarah utilized perineal massage to prevent vaginal tears, although Sarah is unfamiliar with such terminology. An energetic 85 in 1985, Sarah continues to practice, although her self-imposed restriction to attend births only in her own home has caused her practice to dramatically decline. Sarah's granddaughter, currently apprenticing, plans to continue this family tradition.
A contrasting image is Rosie, an African American woman born in 1892 south of Shreveport (Rosie 1985). Coming to midwifing not through a religious calling, Rosie simply responded to meet the needs of her community. When public health nurses first approached her, Rosie was already forty years old, married, and had a high school education. Rosie, with her husband and six children, worked a small farm. Not coming from a family that had a tradition of midwifery, though well aware of its demands, she resisted recruiting efforts until convinced that the community need was desperate. She felt that a good Christian woman must help those truly in need. Trained by public health nurses in both midwifery and sanitation techniques, she was licensed after attending one birth. She enjoyed the midwife meetings which provided opportunities to communicate with other midwives and learn new methods. Rosie considered midwifery a serious responsibility. She states, "It is a job, and sometimes it's worrisome. Sometime you feel bad. Sometime the patient be taking it so hard. Tears come to your eyes and drop down on the patient. It is a job." One reason she felt this responsibility was because the physician in that area made it clear that she should not call on him unless absolutely necessary. One time a Mexican woman's baby was coming foot first. The husband refused to call a doctor since he was illegally in the United States and had no money to pay. Rosie called anyway, but the doctor instructed her to handle it. "I had to do it, so I did. I had to take my hand and get that other foot. That was a big, old live baby."
Clearly, Sarah and Rosie approached midwifing quite differently. The difference in attitudes between Sarah and Rosie can probably be attributed to the fact that they entered the practice for different reasons - Sarah's being one of divine inspiration, while Rosie bowed to the pressure of others. As a result, Rosie followed the official regulations more seriously and retired upon request. Unlike Sarah, Rosie did not pray for guidance in handling a birth.
In Louisiana, public health nurses have played an important role with midwifery (Lange 1949, Ziegler 1949). By the 1920s, the public health system supervised midwives, insuring their conformance to sanitary guidelines. This system, based on mutual support, respect, and need evolved among the doctors, nurses, hospitals, and midwives. Midwives were free to take any clients, but were encouraged, although not required, to have them examined by doctors at free maternity clinics. In 1938, the State Board of Health provided parish health units a manual for supervising midwives. Public health nurses conducted monthly meetings, usually in homes and churches, to review these sanitation guidelines, and for the most part did not attempt to teach midwife techniques. That religious inspiration permeated their dedication to this craft is evidenced by the fact that the meetings opened with a prayer and a hymn. The nurse reviewed portions of the manual, inspected the midwives' equipment bags, and distributed free supplies of gauze, string, and silver nitrite used to protect the infant's eyes from venereal disease. Public health nurses gathered birth data from midwives at these meetings. The meetings culminated with singing the midwife song to the tune of "Give Me That Old Time Religion." Most enjoyed these meetings because they could exchange information and sharpen skills, as well as socialize, although a few midwives resented them, sensing this as an intrusion into their practices.
The parish midwife programs varied from place to place. Some nurses proved to be very supportive and developed a special relationship with midwives that was often fondly remembered. Midwives filled a need in communities that the doctors and clinics simply could not meet. (Some nurses candidly admit that there is still a need for such services in rural parishes.) Other nurses were not as supportive and felt that midwife practices endangered women. Prompted by these feelings, such nurses worked to force the midwives out of practice. A few public health nurses convinced midwives that they could no longer be licensed. Whether or not the public health nurses were supportive depended on the individual nurse's value system concerning medical care and was not based on ethnic, racial or official bias. Nurses supportive of midwifery could be found in both urban and rural areas.
Prior to 1950, Louisiana reported fetal death rates higher than the national average. Frequently, physicians felt that midwives contributed to many infant and maternal deaths. On the other hand, public health nurses who worked more closely with the midwives credited them for successfully coping with difficult situations. Theoretically, midwives handled low risk mothers, but their definition of low risk was much broader than the definition presently employed by obstetricians. Midwives often worked with women who had received little prenatal care, experienced health problems, had poor nutritional habits, and lacked sanitation. Once midwives adopted modern sterilization techniques, the fetal death rate declined. Most public health nurses proudly remember the cooperation shared between doctors, nurses, and midwives.
The maternity care system changed dramatically during the 1950s. As midwives gradually retired, few younger women undertook apprenticeship. Many apprentices did not practice, possibly due to the incredible time demands on a midwife's family and the minimal monetary return. However, just as important may be the fact that midwifery and home birth had become associated with poverty. Consequently, "being modern" meant having a hospital birth attended by a physician. During this same time, the State Board of Health placed more emphasis on expanding hospital systems and improving the supply of doctors. Charity hospitals expanded by establishing more free clinics. The State Board of Health estimates of practicing midwives illustrate the dramatic decline of midwifery. In 1924, approximately 2500 women practiced. By 1949, the number had declined to 1200 (Louisiana State Department of Health 1924-25, 1950-51, 1954-55). Since the 1950s, midwifery has been predominately an African-American occupation, and the clients predominately minorities. This probably explains why many researchers today consider midwifery in the South an African American experience. It is possible that researchers have made this conclusion because African Americans simply retained the practice longer than other ethnic groups. More research is needed before further conclusions can be made.
By 1970, all but a handful of midwives had retired. Ironically, the next decade saw a gradual renewal of interest in midwifery. Two different groups of young women began training to be midwives, again as in the past, for different reasons. The first group, most closely allied with older midwives, reports a similar religious calling. Many of their clients belong to various rural Pentecostal churches promoting home births without physicians. Some families call upon midwives, while others rely upon church members with various amounts of training and experience.
The second group of midwives grew as a social backlash against what has been perceived as impersonal medicated hospital births. Young, urban, middle class women seeking the family-centered birth experience of home births frequently could not locate older folk midwives. These young families often opted to do without medical backup in order to have a midwife attend their deliveries. In recent years, these women have begun to apprentice themselves to the few remaining midwives, while others train themselves in isolation or join with one another in study groups. Some formed professional organizations and lobby to improve the legal status of midwifery. Some of these young middle class midwives do not consider it a religious calling, but they share that same intense desire to participate in this rite of passage. They feel honored to assist in normal births, preferring medical backup to aid in any complications beyond their skills.
Louisiana differs from other parts of the Unites State in many ways. Its midwifery tradition appears to do likewise in three major ways. First, unlike other Southern states, midwives from most ethnic groups practiced throughout the state. Second, both the native born and the foreign born historically preferred a midwife as birth attendant. Third, midwifery was prevalent in both urban and rural areas. Midwifery in Louisiana resembled other parts of the South in that the midwives gradually retired and were not replaced by younger women from the folk communities. However younger, urban, middle class women spurred by a desire to improve their own birthing experience began practicing midwifery. Midwifery is an ancient practice that has reemerged in this world of high technology. Examining midwives of our past and present will add immeasurably to our understanding of this unique feminine rite of passage - that of giving birth.
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