Like in most places in the United States prior to the 1900s, if you were living in southeastern Kentucky and were expecting a child, you were planning to have that baby at home. Your birth would either be attended by a “granny” woman (lay midwife), or if you were living too far from others or if you chose, you would have your baby unattended or amongst other experienced mothers. In very rural areas throughout the United States the outcomes were dismal as compared to today’s standards. “For every 100,000 live births, over 800 resulted in maternal death (vs. 7.7 per 100,000 in the US today), and 100 out of 1000 children died before their first birthday (vs. 7.2 per 1000 in the US today)”(CDC, 1999 – Achievements in public health, 1900-1999: healthier mothers and babies. Morbidity and Mortality Weekly Report, 48 (38); 849-858). The reason for this cannot be blamed solely on the lack of professional training of the “granny” midwives. These women were trained through experience and apprenticeship to care for birthing women and ailments throughout the communities. Mothers trusted their “granny” midwives at a time when seeing a physician was not possible and often was not preferred as outcomes for doctors were not better nor were doctors cleaner in their procedures.
During the post Civil War period industry came to the mountains, and along with it poverty like eastern Kentuckians had never known before. Our way of life was interrupted and changed. No longer did we depend completely on our own hands to provide us with food, but we came to rely more and more on money for our livelihood. We were no stranger to hard work as prior to coal mining we were mostly subsistence farmers. However, as our hills were logged for trees, our families sold the mineral rights of the land, and our men began to work in the coal mines, we saw less food coming in from our family farms. In the early days of coal, men risked their lives just to “owe my soul to the company store” as the lyrics of the popular song states. The resulting poverty escalated and is still an issue here today, though media has a way of exploiting it.
With this poverty women saw harder lives. Their work around the home was increased just to make ends meet. Strenuous chores that were often a husband’s duty, especially during the time of childbearing, were dependent on the women to be done as men moved to work outside the home and off their own land. In many cases, there were other children to be tended to, as we had some of the largest families in the United States at that time. Food became less and less, so women were entering pregnancy malnourished. The combination of these things made pregnancy a risky state of being for women during this period.
Currently, the WHO (World Health Organization) believes that 85-95% pregnancies can be expected to go perfectly (“Care in normal birth:Report of a technical work group.” 1999, Geneva: WHO). With that in mind, it would be plausible to think that the majority of the pregnancies/births that “granny” midwives attended also should have been expected to go normally and their training of experience sufficient to handle the majority of complications that they would see. However, when the many factors listed above made the mothers no longer low risk, and without advanced medical training for the “granny”women to address situations that result from high risk pregnancies, the maternal/infant mortality rates were not what they could have been under better conditions.
Fortunately, some brave women saw this issue and devoted a portion of their lives if not their entire lives to helping the families of mountain communities. Their efforts changed the environment for childbirth in the mountains in wonderfully positive ways. One such woman was Mary Breckinridge, the founder of the Frontier School of Midwifery and Family Nursing. Breckinridge was inspired by the loss of her two children and husband to help others who might experience the same devastating grief. She saw that the best prenatal care being received at the time was through the nurse midwifery model which she saw in practice in Great Britain. Breckinridge and a team of dedicated teachers, volunteers, and nurse midwives came into the mountains to assess and improve upon the situation with great results. Breckinridge believed in meeting the people where they were instead of making them conform to requirements of receiving healthcare in outside clinics and hospitals. She and the nurse midwives that worked with her continued to deliver babies safely in women’s homes through medical understanding. They worked with “granny” midwives, who were willing, to encourage them to let go of invasive techniques that they might have been using to speed labor along, and advised nurse midwifery training.
The following is a video about FNS, it’s history and current activities.
During the 1910s-1920s physicians became better organized and had more uniform training. Upper class women began to seek physician care for childbirth, and people began to look at homebirth and midwifery as something only for the backward and lower classes. In eastern Kentucky however, the people did not have access to doctors and hospitals. The care that nurse midwives were providing mountain women was exceptional, and the mortality rates improved for both mothers and infants despite births not being attended by physicians or taking place in hospitals.
In the mountains of eastern Kentucky, birth remained something that took place in the home for most women well into the 1960s. Nurse midwives continued to serve mountain women. Strong women like Peggy Kemner remained in the mountains loving the women she served in their most transitional moments. These women met the needs of the community on horseback or in rugged terrain vehicles as roads were more like paths in those days.
The following video is a short bit on Peggy Kemner and her work on Stinking Creek.
As the country moved toward the hospital as a place of birth, we began seeing an increase in childbed fever. Physicians began using procedures and instruments that caused harm to mother and baby. A national study done in 1925 (around the time Breckinridge came to the mountains) concluded that “untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries.” (The Official Lamaze Guide: Giving Birth with Confidence, 2005)
Even the “untrained”, “granny” midwives were having nearly equal results in homebirths that physicians were having in hospital births when advanced medical procedures were not required for delivery. Despite this male doctors became the preferred birth attendants, and birth nationwide moved out of the home and into the hospital (The Official Lamaze Guide, 2005). In the 1970s with the construction of new hospitals, roads, and clinics in the mountains, we also experienced the shift. Mountain women no longer wanted to be seen as having backward ways, or being too poor to afford modern medical care, and they began to seek physician healthcare instead of healthcare meeting them through the nurse midwives.
Please visit again soon for the continuation of this three part series. I will be writing about the current state of birth in eastern Kentucky.
Many happy days to you and yours,