Katherine L. Keith, Marcia Brennan, P. Preston Reynolds

The African American midwife is a controversial figure in the history of the South. Although lay midwives served as the primary health care providers to many rural communities well into the mid-1950s, they were often dismissed as ignorant, superstitious, and poor substitutes for trained physicians. They were blamed for high maternal and infant mortality rates and scorned by obstetricians who resented the persistence of lay practitioners in their field. Against such opposition, legislators and public health officials who recognized the value of the midwife struggled to justify their decision to license and train midwives rather than attempt to eliminate them. Existing scholarship on this period in the history of midwifery has addressed this subject from historical and anthropological viewpoints. Using several photographs of midwife classroom training from the American College of Nurse-Midwives’ Collection at the National Library of Medicine, however, we can also explore this topic from a visual culture perspective. This approach enables us to interrogate the ways in which documentary photographs were instrumental in establishing midwives’ credentials and cultural identity at a key transitional moment in the history of the midwife and of public health. Visual analysis of these photographs suggests that while they can be viewed as a celebration of efforts to improve maternal and infant health care, their primary purpose was to refute the claims of those who opposed midwife education on the grounds that lay midwifery was unequivocally dangerous for patients and damaging to the advance of professional obstetrics.

          Historians of visual culture use visual evidence to better understand a historical moment and its attendant codes of representation as embedded in their historical context. Applying their techniques to archival photographs means doing much more than just reading seemingly transparent pictures as recorded facts. Formal analysis focuses on the literal “form” of an image. How does sanctioned narrative become implicitly encoded in formal patterns? How are elements such as line, shape, space, color, balance, and contrast utilized? Where is the eye drawn and what features facilitate that movement? We must break down the foundational components of an image to understand how it achieves its effect. Iconographical analysis considers objects and figures in light of the associations they would have had for contemporary audiences. In this way, objects are linked with concepts or additional meanings. Finally, we must acknowledge that these images are socially, culturally, and historically constructed and thus not limit our interpretations to the ostensible intentions of the photographers. As literary critic Northrup Frye writes, “the question ‘what did the author mean by this?’ is always illegitimate. . . The legitimate form of the question is ‘what does the text say?’”(1) However, before proceeding to any interpretation we should consider these photographs in their historical context.

          Throughout the South and well into the twentieth century African American lay midwives played a vital role in their communities.(2) These women often believed they were individually called by God to practice midwifery and gifted with the necessary ability.(3) Fraser writes, “their involvement in birth and death, their supposed ability to mediate between the real and supernatural world, and their authority in spheres of knowledge closed off to ordinary persons mean that midwives had been regarded with what might be described as awe.”(4) Nevertheless, they were expected to share this seemingly divine gift by attending their neighbors in childbirth, sometimes without payment. A good midwife needed a strong character and ample experience, both as a mother herself and as an apprentice to an older midwife. She often had a personal connection to the mothers she attended and would stay with them throughout the birth and for days or weeks thereafter.

          Rising concerns about high infant and maternal mortality rates in the early 1900s prompted a steady allocation of federal and state funds to maternal and child health programs, notably by the Sheppard-Towner Act of 1921.(5) Considering that as late as 1940, “nearly half of the babies of all nonwhite American women and 71.1 percent of rural nonwhite women were delivered by a midwife,”(6) public health officials in many states opted to provide training and supervision to existing lay midwives rather than attempt to replace them with physicians or professional nurse-midwives, who were absent from many rural areas.(7) Lalla Mary Goggans, a certified nurse-midwife and administrator for the Florida State Board of Health, reports that the midwives she supervised as a public health nurse in west Florida enthusiastically embraced this new training. They sewed their own white caps and gowns from patterns provided by the health department and made the midwife classes “joyous occasions” when nurses and midwives would share techniques.(8) Goggans herself felt that “warm, understanding relationships” between midwives and nurses “resulted in better care of mothers and babies throughout the state.”(9) Tilghman notes that midwifery training also “presented an occupational opportunity other than farming or domestic work” and a rare chance for African Americans to obtain education and improve their economic status.(10) However, despite the enthusiasm of the training participants and the practical considerations that necessitated the continued use of lay midwives, midwife education had many powerful and vocal opponents.

          As medicine became increasingly professionalized and public health organizations struggled to improve vital statistics, midwifery was subjected to growing scrutiny. The methods of midwives, drawn from personal experience rather than formal instruction and sometimes based only in superstition, were perceived as antithetical to the scientific method and condemned as dangerous.(11) Lay midwives were blamed for the high maternal and infant mortality rates of the period; W.A. Plecker, a county registrar of vital statistics, writes in 1918 of his intention to make the midwife “less a source of danger to the mother and child” through regulation, while another physician less reservedly describes midwives as “a menace to the health of the community, an unnecessary evil and a nuisance.”(12) A great deal of the animus against midwives, particularly the propensity to characterize them as “untrained and dirty,” was rooted in racism.(13) Dr. Felix Underwood, director of the Mississippi Board of Health between 1924 and 1958, describes these women as “filthy and ignorant and not far removed from the jungles of Africa.”(14) Such pejorative rhetoric persisted despite multiple contemporary studies showing that the outcomes of midwife-attended births were the same or better than those of physician-attended births.(15) In a landmark 1912 survey of medical schools, J. Whitridge Williams of Johns Hopkins University found that many obstetric professors “acknowledged that more childbearing women died from improper obstetrical operations than from infection caused by midwives.”(16) Yet despite the evidence to the contrary, for many physicians, officials, and members of the public the stereotypical image of a dirty, ignorant, and untrainable woman employing all manner of ineffective and potentially harmful techniques informed their conception of the black midwife and fueled their support for the regulation if not elimination of lay midwifery.

          Efforts to curtail the practice of midwifery were also driven by opposition from the competing field of professional obstetrics. Many obstetricians perceived midwives as a threat to their emerging specialty and to their reputations as expert practitioners.(17) As one physician writes, “if an uneducated woman of the lower classes may practice obstetrics . . . it certainly must require very little knowledge and skill—surely it cannot belong to the science and art of medicine.”(18) Physicians also argued that by attending patients who otherwise might have come in to the hospital, midwives were limiting the opportunities for student doctors to learn their trade.(19) The American Board of Obstetrics and Gynecology, established in 1930, lent its voice to efforts to protect the dignity and exclusivity of obstetrics as a medical specialty.(20)

Figure 1. Class session at the Tallahassee Midwife Institute, August 1933, Collection of the American College of Nurse-Midwives. Courtesy of the National Library of Medicine.

          A large desk in the foreground establishes a physical barrier between the viewer and the classroom of lay midwife students. You cannot imagine yourself walking into this room because all visible points of entry have been blocked. The effect is to mark the midwifery training classroom as a restricted space, one whose full significance will be discussed below. Neatly arranged on top of the desk is an assortment of books, papers, and gleaming metal pots. Tools of midwifery training, to be sure—textbooks would have provided authoritative instruction and pots may have been used for boiling water or practical lessons in nutrition—but we must ask why these items specifically, these symbols of contemporary medical knowledge and hygienic practice, were chosen to make up what becomes a collective icon of modern midwifery. Finally, the photographer’s reflection in the vanity across the room further defines the nature of this restricted space by making visible the oversight by the public health department that has hired him. His actual and reflected gaze permeates the classroom, the raised camera implying a role as monitor, not just observer. Here the techniques of surveillance are both embodied and reflected in the iconic properties of the image itself. The full implications of this oversight require investigation.

Figure 2. A church used as a classroom for training midwives in South Carolina, c. 1940. Photo by E.S. Powell, Collection of the American College of Nurse-Midwives. Courtesy of the National Library of Medicine

          Analysis of a related image, this one of a 1940 midwife training session in South Carolina demonstrates that the inclusion of these elements is not incidental.   Again there is an explicit separation between the classroom and the observer—the elevated vantage point sets the viewer decidedly apart from the midwifery training, looking down on the scene from above. The modern midwife is again defined by her attention to hygiene, as conveyed by the model clean birthing environment that takes center stage, and a reliance on textbooks, as embodied by the figure of the instructor with her back turned. Significantly, the documentation accompanying this photograph indicates that this training session was affiliated with Laura Blackburn, a registered nurse, nurse-midwife, and later member of the South Carolina State Board of Health who devoted her life to the training of granny midwives. She developed and ran the Penn School Midwife Institute in Frogmore, South Carolina. This documentary photograph features a crucial play between anonymous, generic identities and the history of specific, notable figures in nurse-midwifery, discussed further below. In this image in particular, the viewer’s attention is drawn to the figure of the instructor in the foreground. Compositionally we see an inverted triangle with the audience at its base and the instructor at its apex. The resulting sense of convergence is reinforced by tracing the lines of sight of the audience members, most of whom stare fixedly at the instructor. Yet despite her ostensible position of importance, this faceless woman is denied identification as an individual. It follows then that she does not claim the authority to teach by virtue of personal experience and skill as her predecessor would have done. Instead, her power derives from the uniform she wears as a talisman against the scrutiny of the class and the written sources she turns to consult. Finally, a group of white men and women is prominently placed in the center of the classroom. Whether they are public health officials, local physicians and nurses, or additional instructors for the training session, their presence combined with the implied surveillance by the photographer unmistakably communicates the regulation of this space by outside experts. Despite the localized nature of much of the scholarship on the history of midwifery, Gertrude Fraser has argued that similar social attitudes, demographics, and sources of funding led to a regional coherence in the way public health institutions approached midwife regulation.(21) As the shared features of these two images tell us, this coherence extends to the visual culture of midwifery training.

          The context of these images, each taken at the behest of the state board of health that sponsored the training sessions, will help us understand why the motifs of separation, oversight, and signifiers of hygiene and modern medicine are so prominent. As Tilghman writes, the support for midwifery training “was more associated with the realities experienced by poor white and African American women who were pregnant rather than a desire to further develop and sanction the field of midwifery.”(22) Florida and South Carolina were among the states whose legislators recognized that many rural communities could not afford to lose the care provided by local midwives.(23) Goggans, who organized the 1933 Tallahassee Midwife Institute, reported in 1940 that many west Florida counties still had no resident physicians and no hospital within a hundred miles.(24) In South Carolina, midwives still delivered sixty percent of rural African American babies in 1949.(25) In both states public health officials decided to institute licensing and training programs with the goal of improving access to care and the quality of that care. As Laura Blackburn wrote, “we cannot eliminate the midwife until we can replace her.”(26) However, justifying this failure to eliminate lay midwifery to obstetricians and those who blamed midwives for the high mortality rates was an ongoing battle, one that was negotiated in part on a visual level. On the surface, both photographs advertise the states’ efforts to improve maternal and infant health. They celebrate the existence of these education programs, in which the midwives themselves seem proud to be taking part. However, their primary function is to calm the fears of midwifery’s opponents by presenting a new image of the black midwife that directly counters her stereotypical characterization as unclean, unsafe, and a threat to obstetric medicine.

          Part of the work these images perform is to convince physicians, officials, and members of the public of the safety of the trained lay midwife. For those who believed the propaganda denigrating midwives, the idea that they would have an official role in the effort to improve maternal and infant mortality was ludicrous. To answer this concern, these photographs present a vision of the black midwife that contradicts the conception of her as necessarily dirty, unpredictable, and dangerous. The charge of uncleanliness is symbolically countered by the crisp white uniforms of the students in the South Carolina image, the color white being associated with sterility. Likewise, the prepared beds, metal pots, and other trappings of hygienic practice in both photographs imply that a midwife-attended birth can approximate the purported safety of the hospital setting. Meanwhile, the perceived threat of midwives applying their own superstitious and highly variable techniques is defused by an emphasis on standardization. As discussed above, the prototypical midwife in the South Carolina image—the instructor with her back turned—is denied individuality. In the same manner, the individual nature of each of her students is masked, another function of their uniforms. There is no room here for personal knowledge and experience, only adherence to the proscribed practices of modern medicine, an externalized body of knowledge signified by the textbooks on which this new image of the midwife is shown to depend.

          The overarching suggestion that the public health system has complete control over midwifery training, and ultimately midwifery practice, answers the fear that midwives might receive modern instruction yet continue their traditional practices. The concept of oversight is made visible in these images and the overseers are given prime vantage points from which to observe. As mentioned above, in Florida the photographer’s gaze pierces through the center of the classroom, its reflected quality providing a multi-angle view of the training space.

Figure 3. Midwife students gather on the steps and porch. Penn School, Saint Helena Island, South Carolina. Collection of the American College of Nurse-Midwives. Courtesy of the National Library of Medicine

          The officials in South Carolina, meanwhile, are located in the physical center of the class, where they can both see and be seen, reminding the midwives of the regulations under which they now operate and the attendant consequences of breaking the rules. The idea of oversight finds a parallel in the techniques of surveillance imaged in, and instantiated by, the photographs themselves. The figurative reigning-in of the midwives is echoed by their placement in rigid seated rows and by a third image, this one from the Penn School Midwife Institute in South Carolina  Here, a group of midwife students poses on the steps of a building. The overall composition is pyramidal, with the verticality and apex of the pyramid reinforced by the classical white post of the central column. The photographer’s use of classical compositional elements, including the pyramidal construction, careful symmetry, and use of the gazes of various figures to draw the eye around the tableau, inserts these women into the same western academic tradition that grounds medical science. Meanwhile, recording their willingness to pose just so, standing, sitting, turning their heads as they are told, asserts the malleability of midwives in response to regulation. The implied message to the viewer is that these students are obedient and will in fact only use those practices sanctioned by the public health system. Whatever one’s opinion of midwives and their capabilities, the health of mothers and infants is ultimately in the hands of modern medicine.

          These images also work to convince physicians that midwives pose no threat to the advancement of obstetric medicine. The distance interposed between classroom and viewer can be interpreted as a separation of midwifery from general obstetrical practice. In this sense, the restricted space defined in each photograph becomes one of containment. The characterization of these groups of midwives as small, isolated, and controlled implies that an eventual elimination of midwifery would be not only possible but relatively simple. The containment of the profession also implies the containment of the threat of disease and other negative outcomes. Meanwhile, the midwife’s ability to function as an independent birth attendant is downplayed. The students’ uniform likens them to nurses, whose ancillary position and submissive professional attitude toward doctors was well established. The focus on the midwife’s role in preparing a sterile birth environment portrays her as little more than a peripartum domestic assistant. Meanwhile, her depicted dependence on medical texts implies an inferior standing compared to the physician, with his greater access to and command of the body of knowledge comprising contemporary medicine. As presented in these images, midwives are no substitute for the obstetrician’s expertise.

          An additional image sheds further light on both the form and the content of the messages being conveyed, and reinforced, through the repetition of the visual patterns and social codes featured within this corpus of documentary photography. In a photograph taken by E.S. Powell, who also documented the South Carolina training session discussed above, nurse-midwife and Berkeley County public health nurse Eugenia Broughton prepares to lead a class of midwives in song. 

Figure 4. Eugenia Broughton. Photo by E.S. Powell. Collection of the American College of Nurse-Midwives. Courtesy of the National Library of Medicine

She sits before a blackboard filled with writing, the lower-right portion of which is clearly identified as “CHORUS,” and reads from a published booklet. The use of lyrics and melodies to facilitate teaching and memory recalls the oral tradition that grounded the old apprentice model of midwifery, but now the practice is reconfigured as a standardized didactic exercise. This suggestion of broad standardization reinforces the public health system’s control of modern midwifery and the resultant safety of midwife-attended births. However, the focus on oral communication at all would have undermined midwives’ efforts to retain their role as independent birth practitioners. The implication that many midwives are illiterate and thus require instruction through simplistic songs does nothing to challenge the inherent racism of their opponents. It also underscores their inability to pose a serious threat to obstetric medicine, as the development of a true professional class requires literacy.

          The blackboard’s content is equally troublesome (see Appendix). The song urges midwives to register every birth they attend, a practice that was often legally required even in states with minimal regulation of midwifery.(27) There were certainly tangible benefits to registration, including the ability to prove one’s age and one’s status as an American citizen. As the song states, with a valid birth certificate a man would “be eligible to earn an honest wage” and “Receive a monthly pension, if He can prove his age.”(28) Birth registration also provided documentation of the number of women still calling on midwives for birthing assistance, potentially helping to establish the ongoing need for lay midwives and to elicit additional funding for midwife training programs from governmental agencies. However, this inscription of personhood into the official textual record was at once democratizing and controlling. Birth certification provided an easier means of managing both lay midwives and the general black population, and of primary concern in the South was the question of racial purity. Many states required the race of parents and children to be recorded and misrepresenting a newborn’s race was a felony in Virginia.(29) County registrar Plecker shared his expectation that each midwife would “police the women she attended so that no mixed race children got the opportunity to ‘pass’ into the white world.”(30) Literacy for midwives came to be defined as the ability to fill out a birth certificate and those who could not or would not properly register each birth lost their license to practice.

          Finally, above the blackboard’s neat rows of handwritten lines hovers a printed banner that explicitly expresses the overall mission of public health education. Conveying an axiomatic embodiment of the public health ethos, the text reads: “Public health is the art and science of preventing disease, prolonging life and promoting physical and mental efficiency through organized community effort.” The written statement thus provides a complementary textual reinforcement to the visual message conveyed in the classroom photographs featuring desktop still lifes of books, papers, and metal pots, as discussed above. Viewed collectively, these implements unite theory and practice, the ideal and the real, the mind and the hand—the various elements that comprise the conceptual and existential domains of midwifery education. The banner presents a similar thematic conflation of art and science through the combined virtues of efficiency and organization which, once again, both shape and are shaped by the domains of the “physical and mental.” The instructor herself is positioned directly under the horizontal banner and at the visual midpoint of the image, thus locating her both compositionally and ideologically at the center of the message. Moreover, while the viewer is close enough to discern the instructor’s individual features, in this photograph—as in all of the images examined throughout this essay—the figure has a decidedly generic quality. That is, while specific individuals are depicted, the imagery promotes the creation of a professional community of midwives in part through the negation or erasure of their specific individual identities. Here, Nurse Broughton’s downcast eyes fail to engage the viewer or reflect any agency beyond her role as a conduit for text provided by a third party. Likewise in Figures 2 and 3 the standard convention of the group portrait pose, coupled with the midwives’ white uniforms, aprons, and caps all contribute to signifying the uniformity of the women’s professional training and identity. In this way, the group portrait becomes a group genre scene, one that presents specific individuals in order to reinforce larger, impersonal conceptions of the social identities of midwife nursing students and their instructors. Thus in contrast to previous stereotypes that associated African American midwives with a sense of personal calling, occultism, and superstition, the official documentary photographs instead emphasize a standardized, scientific approach to midwifery that is based on reproducible knowledge that is designed to be a product of, and to appeal to, the culture of evidence-based medicine sponsored by state health boards.

          As this suggests, one of the intriguing paradoxes that emerges within this corpus of archival photography is the absence of subjects through their serial repetition. Just as the prominence of the empty white bed in the center of the classroom in Figure 2 indicates the absence of the obstetric patient, the individual person becomes a generic placeholder rather than an identifiable subject. Through the “sterilization” and evacuation of personal identity, public health imagery is again sanitized of messy human complications and particularities, just as reproducible knowledge is communicated through standardized, regulated practices that are reflected in the stagecraft of the imagery itself. In short, while the archival record clearly indicates the presence of known individuals of considerable stature, the photographs instantiate the ways in which the professional authority of these individuals was constructed through the erasure of personal identity in order to privilege uniformly reproducible, generic ideals.

          In so doing, the images shed important light on the work that these photographs are designed to perform in constructing a public identity for midwives as organized, orderly, clean, educated, procedural, and methodical professionals who are trained to make appropriate healthcare interventions. The midwife population is repeatedly represented as a trained subclass within the professional hierarchy of medicine, through imagery that both documents and reinforces the midwives’ established place within a larger system of medical knowledge and practice. Although it is doubtful that such arguments, whether visual or verbal, significantly quieted the opponents of midwifery, this new conception of the black midwife spoke directly to their professed concerns. However, although the sponsors of midwife training may have intended to support lay midwifery as long as it was needed in the South, these photographs reveal several factors that may have contributed to the institution’s eventual decline. First, the fact that the production of such images was necessary even as the training programs were underway implies the continued presence of a significantly large and powerful opposition. Even Adah Belle Thoms, champion of educational and employment opportunities for black nurses, saw lay midwifery as nothing but “a temporary measure” until enough public health nurses could be trained “to take over this work.”(31) Second, these images were commissioned and circulated by the state boards of health. In part, this can be seen as valuable public relations efforts on the parts of the participating states, as the photographs ostensibly provide evidence of the granting of professional opportunities for women of color in the healthcare profession, just as they apparently show the state’s investment in vulnerable rural populations, while all the time preserving a sense of sanctioned control, order, and hierarchy. In fact, the midwives seem to have had no control over their own visual representation, which may have hindered any attempts at professionalization and their ability to represent themselves and fight for a continued place in health care. Finally, several signs point to the changing role of the midwife in this period. Whereas before the midwife was intimately involved in each birth, she is now shifted to the periphery. The waning importance of a personal connection between mother and midwife under this new model is reflected in the absence of a physical patient in these images, whether she is replaced by a mannequin or an empty bed. Meanwhile, the authority derived from a spiritual calling and the community’s recognition of a midwife’s skill has been replaced by validation from an external source, the board of health. Midwives may have embraced these changes, eager to better serve their communities by participating in training sessions and adhering to the techniques of modern medicine. However, if the special role of the midwife was disregarded or gradually forgotten as she was transformed into an agent of the public health system, there would have been little reason to seek out a midwife as doctors and hospitals became more accessible. The individual lay midwife’s figurative absence, reflected throughout the visual record, ultimately became a literal one.

Appendix

Whenever you deliver perhaps a Baby Boy
Remember he is human, not just a little toy.
His Birth should be recorded within ten days or less
And in years to come, you will be blessed.

[We] know that it’s important, a solid standard rule
He’ll need birth registration to go to any school
To prove He is the right age to marry or to vote
So be sure His Birthdate you report.

He’ll need it for enlistment or maybe go ABROAD
Producing his birth record will prove he’s not a fraud
It’ll make Him mighty happy if He can really s[ay]
“I’m a native of the USA”

He’ll then be eligible to earn an honest wage
Receive a monthly pension, if He can prove his age
When sixty-five or over, he then will in due time
Live in comfort, peace, and sweet sublime

CHORUS

Be sure His name, the date, the place are right
If not, in time he’ll be in quite a plight
Check and re-check, then have the mother sign
[An]d you will have great peace of mi[nd]

_________________________________________
1. Raymond W. Gibbs, Jr., Intentions in the Experience of Meaning (Cambridge: Cambridge University Press, 1999), 247.
2. Judy Barrett Litoff, ed., The American Midwife Debate: A Sourcebook on Its Modern Origins (New York: Greenwood Press, 1986), 4-5.
3. Laura Blackburn, “The Midwife Problem in Rural Areas of the South,” The Trained Nurse and Hospital Review (August 1939): 3; Lalla Mary Goggans, personal reflection, “The Wonderful Years of Working with Mothers and Children – 1930-1972,” Lalla Mary Goggans Collection, American College of Nurse-Midwives Manuscripts, National Library of Medicine: 8; Gertrude Jacinta Fraser, African American Midwifery in the South: Dialogues of Birth, Race, and Memory (Cambridge: Harvard University Press, 1998), 188.
4. Fraser, 143.
5. Sally Austen Tom, “With Loving Hands: The Life Stories of Four Nurse-Midwives” (Master of Science diss., University of Utah, 1978), 20. Copy located in Lalla Mary Goggans Collection.
6. Charlotte G. Borst, Catching Babies: The Professionalization of Childbirth, 1870-1920 (Cambridge: Harvard University Press, 1995), 157.
7. Blackburn, 1, 5-6; Deola M. Lange, “A Talk by Deola M. Lange” (presented to the Negro Medical, Dental and Pharmaceutical Association of Louisiana, c. 1948), 2. Copy located in American College of Nurse-Midwives Manuscripts; Litoff, 7-8; Tom, 24.
8. Goggans, 5, 7.
9. Ibid, 6.
10. Joan Sylvia Graham Tilghman, “Conclusions,” in “A Study of African American Lay Midwifery Experiences in Rural South Carolina 1950-70” (doctoral dissertation, University of Miami, 2002), 123.
11. Lange, 2; Tom, 14.
12. Fraser, 68; James Lincoln Huntington. “The Midwife in Massachusetts: Her Anomalous Position,” in Litoff, 113.
13. Fraser, 71.
14. Ibid, 89.
15. Blackburn, 2; Carolyn Conant Van Blarcom, “Midwives in America,” in Litoff, 169; Fraser, 81-83.
16. Borst, 109; Joan Sylvia Graham Tilghman, “Regulation of Midwives,” in “A Study of African American Lay Midwifery Experiences in Rural South Carolina 1950-70” (doctoral dissertation, University of Miami, 2002), 30.
17. Fraser, 83.
18. Joseph B. De Lee. “Progress Toward Ideal Obstetrics,” in Litoff, 102.
19. Tilghman, “Regulation of Midwives,” 26.
20. Borst, 115.
21. Fraser, 27.
22. Tilghman, “Regulation of Midwives,” 55.
23. Betty Sadler, “Midwives Never Stop ‘Rocking Them Babies,’” The State – Columbia, S.C., November 22, 1968; E. R. Hardin, “The Midwife Problem,” in Litoff, 146.
24. Goggans, 15.
25. Fraser, 37.
26. Blackburn, 6.
27. Fraser, 35.
28. [Eugenia Broughton] photo by E.S. Powell. Collection of the American College of Nurse-Midwives. Courtesy of the National Library of Medicine. http://ihm.nlm.nih.gov/images/B09994.
29. Fraser, 49, 74.
30. Fraser, 76.
31. Adah B. Thoms, Pathfinders: a history of the progress of colored graduate nurses: with bibliographies of many prominent nurses (New York: Kay Printing House, 1929), 229. Adah Belle Thoms graduated from the school of nursing at Lincoln Hospital and Home (New York) and served as president of the NACGN from 1916 to 1923. Pathfinders was the first published record of the experience of black nurses in America.