Midwifery is an effective model for providing prenatal health care and is proven to result in lower C-section rates and fewer preterm births. Though it has roots in Black, Indigenous, and immigrant communities, Black people face systemic barriers to practicing midwifery. As a result, birthing people in their communities may have less access to birthing care and birthing environments that feel safe and comfortable.

Drawing on new Urban Institute research about pathways to develop and retain Black maternal health workers, we explore the history of midwifery in the United States, current challenges, and promising practices for advancing midwifery and supporting Black midwives.

The history of midwifery in the US is fraught

Midwifery was the primary form of prenatal care in the US through the 19th century. Black, Indigenous, and immigrant women passed down traditional healing practices and knowledge through apprenticeships with experienced midwives in their communities.

In the early 20th century, the burgeoning medical profession began to intentionally devalue and eventually criminalize midwifery, even though early research studies found better maternal outcomes for midwife-attended births than hospital-based births. Public health professionals fought to replace home births with more “professionalized” prenatal care by stigmatizing traditional midwifery and characterizing home births as dangerous and unsafe. These tactics were effective: midwives supported around half of all births in the early 1900s, but by 1930, the share had dropped to 15 percent.

Beginning in the mid-1920s, the federal government aimed to decrease maternal mortality rates by funding joint nurse-midwifery programs that included training and licensure. As nurse-midwifery formalized, white practitioners began to dominate the profession. The women of color and immigrant women with whom midwifery originated and who had long used the practice to care for their communities were delegitimized as white nurse-midwives excluded Black women from their schools and wielded state legal and regulatory enforcement to control and suppress Black midwives.

Though perceptions of midwifery are changing, challenges remain for Black midwives

Midwifery has since regained traction; today, the medical establishment recognizes the effectiveness of midwifery, and demand for midwives has been increasing. Yet varying types of midwifery exist with differing credentialing and practice privileges. These scope of practice laws limit many from practicing to the full extent of their education, clinical training, and certification.

Black midwives play an important role in ensuring Black mothers and birthing people can access prenatal care that makes them feel secure and cared for. It also improves outcomes: racial concordance in health care, or when a patient and provider share the same racial identity, has been shown to improve the quality of health care people of color receive. This is especially important given that the US health care system disproportionately harms Black communities—especially Black mothers and birthing people, who experience negative birth and pregnancy outcomes at higher rates than other racial and ethnic groups.

Still, the number of Black clinicians in the United States is disproportionately low. A 2021 report found that only 7 percent of certified nurse-midwives and certified midwives identified as Black or African American (PDF), despite accounting for 14 percent of the population. In contrast, nearly 86 percent of midwives identified as white, when white people made up 62 percent of the population.

In interviews with Black obstetricians, labor and delivery nurses, and midwives, we found that Black midwives face systemic challenges to entering the professional maternal health workforce, including a lack of funding, mentorship, and support.

The Black midwives we interviewed voiced concerns about the lack of midwifery training programs at historically Black colleges and universities. Forced to pursue their studies at predominantly white institutions, they lacked access to diverse faculty and preceptors and had difficulty finding racially concordant mentors. This also led to the few Black professors available being pressured to advise the many Black students and other students of color who sought their support, creating an unsustainable workload.

The difficulties continue as midwives transition into active practice. Interviewees in our research described going to midwifery school hoping to work within their communities and outside of hospital settings, but many faced financial barriers to providing out-of-hospital care, including requiring physician supervision or collaborative agreements to practice. Several interviewees experienced challenges navigating Medicaid, which aligns with existing findings that inadequate Medicaid reimbursement is a barrier to serving patients with low incomes and incentivizes birthing people to seek hospital births instead of paying out-of-pocket for birthing care.

Several strategies could secure a better future for Black midwives

To address these challenges, officials in government, philanthropy, midwife training programs, and hospitals—and other stakeholders invested in removing barriers to Black midwives entering and staying in midwifery—could consider the following steps:

• Increase access to out-of-hospital deliveries by supporting birth centers. In 2016, a California survey found that 40 percent of birthing people were interested in giving birth at a birth center, which is a nonmedical facility for childbirth that prioritizes homelike and wellness-centered care. Black respondents showed the most interest in giving birth at birth centers. Pairing grants and donors with Black-led birth equity organizations to create birth centers would increase job opportunities for Black midwives and ensure birth centers remain stewarded by Black clinicians.
• Partner with professional associations to increase insurance coverage of and reimbursement for home and birth center care. Doing so would allow midwives to provide services to communities with low incomes. Currently, clinicians are seldom reimbursed by Medicaid and other insurance types for midwifery services, restricting who midwives can afford to provide services to.
• Raise public awareness of midwifery and out-of-hospital care. Launching public awareness campaigns could help counter misconceptions about midwives and increase use of and trust in out-of-hospital care options. To support these campaigns, health-focused nonprofit and philanthropic organizations could highlight the work of local midwives. And academic and other organizations could bring in clinicians of color to speak with students at high schools and community colleges to provide culturally relevant resources outlining midwifery paths for Black students.