April 11- 17 is Black Maternal Health Week. This is not a statistics post. This is a history post. Because you cannot understand the crisis without understanding how we got here.
There is a woman who doesn’t appear in most medical textbooks. She walked miles in the dark, carried a black bag, and knew things about birth that no medical school had yet codified. She was called a granny midwife, a community midwife, a “lay” midwife (though that last term always gets me, because there was nothing lay about what she knew or what she did).
She was, in most cases, a Black woman. She was trusted, skilled, and indispensable. And she was systematically pushed out of practice - not because her outcomes were worse, but because she was inconvenient to a system being built around profit, patriarchy, and professional gatekeeping.
That history is not separate from the Black maternal health crisis we face today. It is the crisis.
The Flexner Report (1910): Closing the Door
In 1910, Abraham Flexner published his landmark report on American medical education, commissioned by the Carnegie Foundation. It standardized medical training — and in doing so, shuttered most of the nation’s medical schools for Black students. Of the seven historically Black medical colleges then in operation, five closed in the years that followed. Only Howard and Meharry survived.
The Flexner Report is framed as modernization. But modernization for whom? Its true effect was to consolidate medicine within a white, male, hospital-based model and to delegitimize every form of knowledge that existed outside it. Fewer Black physicians meant more Black communities without doctors, and more pressure on the community healers who remained.
The Sheppard-Towner Act (1921): Surveillance Dressed as Welfare
The Sheppard-Towner Maternity and Infancy Act is sometimes held up as a feminist victory - the first major federal welfare legislation focused on maternal and infant health. Parts of it were genuinely progressive.
But in the South, where the majority of traditional Black midwives practiced, Sheppard-Towner funding was used to set up programs explicitly designed to supervise and ultimately eliminate the granny midwife. Public health nurses - predominantly white, trained in hospital-based obstetrics - were dispatched to require registration, mandate uniforms and approved kits, and subject traditional midwives to observation and “reform.” The framing was of uplift. The function was surveillance, as a prelude to elimination.
The data did not support the narrative. In many rural Southern counties, outcomes with experienced Black midwives were comparable to or better than those in physician-attended hospital births of the era. But outcomes were not really the point.
The Medicalization of Birth: Patriarchy and Economic Motivation
The takeover of birth by medicine was not driven by evidence. It was driven by the intersection of professional economic interest and patriarchal authority over the female body.
In the early 20th century, obstetrics was a struggling specialty. Midwives attended the vast majority of births, charged less, stayed longer, and had generations of community trust. For obstetrics to become viable, birth had to be reframed as a medical event - dangerous, requiring expertise, best managed in a hospital by a (male) physician. State legislatures were lobbied. Licensing requirements made traditional practice impossible for women without access to formal credentialing, which was itself gatekept by race and gender.
The deep irony: many of the techniques that made hospital birth safer - sterile technique, careful hand-washing, skilled attendant continuity - were things traditional midwives had been practicing for generations.
The Granny Midwife: Who She Was, What She Knew
Let me be clear about something. The women who were displaced were not practicing folk magic in the dark. They were empirical practitioners. They knew which positions reduced tearing. They knew when a baby was presenting badly. They knew which herbs slowed hemorrhage and which sped labor. They knew how to read a laboring woman’s body because they had attended hundreds, sometimes thousands, of births.
Among African American communities in the rural South, the granny midwife was often the most trusted person in the community. Her knowledge was intergenerational, transmitted woman to woman, rooted in both African healing traditions and hard-won experience on American soil. This knowledge was not marginal to medicine. It preceded medicine, and in many cases informed it - without credit, without compensation, without acknowledgment.
Suppression Becomes Law (1930s–1950s)
By midcentury, the campaign had largely succeeded. In Mississippi alone, the number of licensed midwives fell from over 7,000 in the 1920s to near-zero by the 1980s. What replaced them was not always better care. It was less care. Rural Black women in the Jim Crow South were denied admission to white hospitals and underserved by understaffed Black ones. They lost their midwives and gained only distance, discrimination, and danger.
While overall maternal mortality rates recorded by the Center for Disease Control plummeted by 90%, by 1950, maternal mortality among Black women was two to four times that of white women. That number has not improved during the intervening 80 years.
The Revival And Who Gets Credit
Beginning in the 1970s, a midwifery revival gathered momentum. The natural birth movement, the homebirth movement, the doula movement - real and important work. Much of it was white-led. And much of it was built, consciously or not, on a foundation of knowledge that came from Black and Indigenous women, without credit, without compensation, without a seat at the table.
The communities most harmed by the original suppression were not centered in the reclamation.
The Doula Movement: Reclamation in Progress
Something is shifting. The contemporary Black doula and midwifery movement is not a nostalgic recovery project. It is a living, political, community health intervention. Organizations like the National Black Midwives Alliance and dozens of others are doing what the granny midwives always did: showing up, staying present, carrying knowledge - now with evidence behind them, with Medicaid advocacy, and with a clear-eyed analysis of why Black women need Black-centered care.
The research is unambiguous. Doula support is associated with lower rates of cesarean delivery, fewer preterm births, and more positive birth experiences - and these effects are larger for Black women. A doula is not a luxury. For many Black women navigating a healthcare system saturated with implicit bias, she is a lifeline.
A Personal Note
I want to name the people who shaped my own understanding of this lineage. Doulas Ana Paula Markel, Haize Hawke, and Erica Chidi have each shown me what it looks like to hold space with both skill and love and welcomed me into a community of support, spirit and science. Midwives Debbie Allen and Jessica Diggs have been collaborators, teachers and touchstones for me in understanding the sacred work of birth keeping. I am grateful to acknowledge my conventionally based mentors, such as Dr Kimberly Gregory, Directory of the Division of Maternal- Fetal Medicine at Cedars Sinai Medical Center and Professor at UCLA and my colleague, board certified OB GYN and herbalist, Dr. Rana Snipe Berry, who recently reminded me about this history. Their work is a direct continuation of the tradition this piece honors.
The Number We Cannot Stop Saying
Black women in the United States are approximately three times more likely to die from pregnancy-related causes than white women.
This holds across income, education, and access to care. It is not explained by poverty. It is not explained by health status. It is explained by racism - structural, interpersonal, and internalized within medicine.
Dr. Shalon Irving. Amber Rose Isaac. Dr Janell Green Smith. Kira Dixon Johnson. These are not data points. These are women.
The history we’ve walked through is not prologue. It is causation. Every policy choice, every closed medical school, every midwife run out of practice - those choices compounded across generations into the mortality statistics we recite today.
What We Owe
As physicians, as birth workers, as anyone who touches this system: we owe an honest accounting of how we got here. We owe investment in Black-led maternal health organizations, in doula training pipelines, in community birth centers. We owe our patients the full truth of their risk and the full weight of our advocacy on their behalf.
And we owe the granny midwives their rightful place in the history of medicine - not as colorful relics of a pre-scientific past, but as the skilled, knowledgeable, community-rooted practitioners they were.
The hands that held us for generations deserve to be held in memory, in honor, and in the living continuation of their work.
Resources: National Black Midwives Alliance | Ancient Song Doula Services | Black Mamas Matter Alliance | Kindred Space LA | The Birth Justice Movement
Dr. Suzanne Gilberg-Lenz is a board-certified OB/GYN, integrative medicine physician, and author of Menopause Bootcamp. She is Chief Clinical Officer at MonarchMD and founder of the Menopause Boot Camp brand.