Author’s note: readers will notice that there is a variety of Appalachian lingo used throughout this blog. This was used verbatim as Mary used it when she personally interviewed the individual midwives. Some of it may be difficult to discern. Words like “ketch” mean ‘catch,’ “hit” generally referred to as ‘it,’ “keer” was referred to as ‘care,’ and “kep” was often referred to as ‘kept.’ It should also be important to remember that even untrained midwives in Southern Appalachia played an important part in healthcare. People like Mary Breckinridge worked to make sure midwives and nurse-midwives received proper training to reduce both maternal and infant deaths.
Mary Breckinridge was a pioneering nurse-midwife who founded the Frontier Nursing Service in 1925. Dedicated to improving maternal and child health in rural Kentucky, she famously utilized horseback riding nurses to reach extremely isolated Appalachian communities. Her innovative model significantly reduced mortality rates and established the foundation for modern American nurse-midwifery. In the summer of 1923, Mary did a little investigating of her own. She chose Leslie, Knott, and Owsley Counties to examine the overall state of old-time midwifery in the mountains.
One of the reasons Mary chose these counties was because of their isolation. At the time of her investigation, the county seat for Leslie County was Hyden with a population of 313; Hindman had a population of 467 for Knott County; and Booneville had a population of 243 for Owsley County. None of the three communities had a railroad at the time of the investigation nor did they have a coal mine. These were truly isolated Appalachian communities.
A Look at Cultural Status in the Counties
In the census for Leslie County, there was one male and one female listed as foreign-born. In Knott County, there were four foreign-born individuals alongside one hundred and fifteen Black residents, descendants of slaves, and a few Black families in Owsley. Mary observed that the African American population was respected and compared favorably to the “foreign” Black individuals brought into nearby mining camps.
A compiled list of fifty-three midwives was established by Mary; her investigation began in early July and concluded in mid-September of 1923. Given the extreme isolation of these communities, and to get a better look and experience of what life was like, Mary would have to set out and go into their natural surroundings and visit their homes. Additionally, Mary spent a significant amount of time talking to young mothers that were served by the midwives as well as doctors, an ‘unfortunate number’ of pseudo-doctors, county judges, and school teachers, among others.
- Four of the midwives lived in the county seats
- Five or six were found on principal waterways, on smaller, rougher creeks or forks
- Three of the midwives were away from home, their histories came from married daughters they attended
- One midwife had been buried the day before Mary visited
During her trip, Mary traveled 650 miles mostly alone, though sometimes a worker joined her for the day. In Leslie County, she spent six days with Miss Caroline Whitney, a fourth-year medical student at Washington University who was at Pine Mountain Settlement School for the summer. Together, they visited six midwives.
| County/State | Number of Midwives |
| Knott | 15 |
| Owsley | 12 |
| Leslie | 10 |
| Perry | 4 |
| Harlan | 2 |
| Breathitt | 2 |
| Jackson | 1 |
| Lee | 1 |
| Floyd | 1 |
| Bell | 1 |
| Clay | 1 |
| North Carolina | 1 |
| East Tennessee | 1 |
| Virginia | 1 (colored) |
The midwives ranged from 30 to 90 years old, totaling 3,193 years among the 53. Their median age was 57, and the average was 60.3. All were married, with five marrying twice and one three times. Eighteen were widows, living with married children or alone. Most husbands were farmers, with one as a storekeeper and farmer, and another as a preacher. One midwife worked as a deputy jailer, while another, elected independently, was the county jailer and ran a boarding house with sixteen beds. Another midwife managed a boarding house with eleven beds. One younger midwife was married to a pseudo-doctor, and their family did not depend on farming.
All but two of the fifty-three midwives had children with the number of children per midwife ranging from one to sixteen. The fifty-one who had children collectively had a total of 448 children, with a median of nine, and an average of 8.5.
Their homes varied from single room, windowless log cabins to modern frame houses. According to Mary, “but generally speaking their homes are poor as well as inaccessible.” That’s not to say they were unkempt; many were tidy with flowers. Ultimately, however, “their mistresses, in ages ranging from 30 to 79, match the homes. Ten midwives, in age from 37 to 89, were filthy, so were their homes.”
Like their homes, Mary noted that their ‘native intelligence’ varied widely. A seventy-year-old midwife with no children told Mary that she always longed to become a doctor, she could not read or write. Two of her nephews were doctors, both graduates of the Medical School in Louisville.
“It cannot be too strongly emphasized that the question of literacy, especially with older women, has no bearing whatever upon their relative intelligence.”
A “remarkable” eighty-six-year-old midwife, the daughter of a former schoolmaster at Booneville, could read and write without needing spectacles. And so the variety continues; one seventy-year-old said she had been a “pure scholar” back int he day and “knew all the words int he blue backed speller.” Two others in their sixties could read and write. A third of them could only read print. The majority of the midwives over sixty were illiterate. Additionally, Mary noted a number of them wore spectacles. When inquiring of this, one said she got a pair from a neighbor, one pair belonged to another’s father, and a third said they could be purchased “from a man in Chicago if you sent him your age.”
Professional Qualifications
According to Mary, none of the fifty-three midwives had no real professional status; “the origin of their obstetrical practices life in unrecorded time.” None provided any post-natal care. Essentially, when the delivery is completed, the mother is “fixed up” and the baby was “dressed” and the midwife went away and generally did not return. There was likely no pre-natal care on behalf of the midwife as well as no nursing care. The mother would usually get up after three or four days.
Was midwifery a calling to these mountain midwives? Generally, no. Mary asked this question to similar replies. “I kep gettin’ ketched”–“bein; ketched at places:”–“I got ketched with a baseborn child”–and one that “somebody just had to be around to catch the babies.” Many of the midwives did not being their practice, “it was thrust upon them.” Additionally, “As neighbors in a lonely county they were called upon for this as well as for every other emergency.” All fifty-three midwives did not receive any training in midwifery; their training generally came from other midwives passing along their own tips and wisdom. There were only four instances in which a midwife professed to have gotten information from a book. In one instance, a “young, clean, and intelligent young woman,” took up midwifery and was married to a pseudo-doctor of whom she learned many bad habits. Mary noted she found a hypodermic syringe in the midwife’s bag and a box of pituitrin, “which she admitted to giving for retarded labor, without any conception of the gravity of her act.” Pituitrin was used to induce labor (historically) and today is used to control pulmonary bleeding.
This led to a disturbing discovery for Mary; the shear number of pseudo-doctors, those untrained and unlicensed to practice medicine. During her investigation, Mary noted she came across five pseudo-doctors in Leslie County along. Equally alarming is that midwives did not distinguish the pseudo-doctors between trained, licensed physicians. “And so not only unsafe and dirty practices are propagated as by authority, but many lives are lost because the midwife sends for a pseudo-doctor instead of a real one.
Aunt Tildy and the “Crossed” Baby
According to Aunt Tildy, she was called to “ketch” a baby, however it was crossed. She wasn’t able to reach the head or the feet; she attempted this all day and night on Friday and sent for two “doctors” on Saturday morning. Aunt Tildy and the doctors attempted to deliver the baby but after over fifty hours of labor, Tildy sent for a doctor in the county seat who could “cut.” Before the doctor arrived, the young mother died. The two doctors initially sent for were pseudo-doctors. Midwives often did not differentiate between “real” doctors and “pseudo” doctors. Aunt Tildy was deeply affected by this. “She described the despair of the dying woman at leaving her young gamily, how she called for her sister and told her to ‘take keer’ of her little children, and how terrible ‘miseries’ ‘kep’ up’ until they had ‘kilt her.'”
As Mary began her investigation, the State Bureau of Child Hygiene had just begun a program with the local county health officers (who were often physicians) to provide basic instruction to midwives. Ten of fifty-three midwives claimed to attend this instruction and even professed changes in methods as a result. Mary noted that those who showed the most benefit from the instruction were those that physicians had taken about and had made a special effort to teach.
Numbers and Changes
Before the Commonwealth required birth registration, none of the midwives had any solid idea of how many mothers they delivered. One seventy-eight-year-old midwife on crutches said she “dressed” over 800 babies and had “never had to have a doctor yit.” Another fifty-year-old midwife said she had about a hundred in eight years. Still yet, another claimed 337 in 27 years of practice, one with 40 years practice claimed over a thousand.
Data from 1922 from the State Board of Health showed:
Leslie County
1 doctor reported 41 births
43 midwives reported 265 births
Knott County
5 doctors reported 37 births
55 midwives reported 396 births
Owsley County
3 doctors reported 66 births
30 midwives reported 163 births
An annual permit for midwives, which also included regulations, had been provided to the ten midwives who attended instruction with the Bureau of Child Hygiene and the County Health Officers. All the midwives that sent in birth certificates were registered with their local registrars per the 1920 act regulating and licensing midwives in Kentucky.
The aforementioned ten midwives claimed they were using silver nitrate solution that was provided them by the state. Two additional midwives said they were using, one said a doctors gave her some and the remaining had never seen but a few had heard of the solution before. The silver nitrate solution was used for ophthalmia neonatorum; it is a severe form of conjunctivitis in newborns, often caused by bacterial infections during birth. If untreated, it can lead to permanent blindness.
Mary noted that equipment and supplies in mountain midwifery was a “minus quantity.” Of ten midwives, seven claimed to carry bags, two of them did not produce them because they were worn out. “One of these began graphically describing the articles that [her bag] contained as we sat at her cabin door, but when I asked to see them, the brush was lost, the oilcloth left somewhere, she was out of Lysol, and did not have any eye drops.” The remaining midwives either had dirty, old handbags, or none at all.
The mountain midwives charged varied fees, “apparently at random,” in all but two cases. These ranged from two to five dollars. Several noted that they made one (cheaper) charge for close neighbors and another charge for people father away, and some asked for more when confinement took longer. Only one charged $1.50; the midwife with the pseudo-doctor charged $10. The general consensus was that families would pay between three and five dollars in most cases.
Techniques, Superstitions, and Catchin’ the Baby
Mary struggled with some of the midwives when it came to learning about their obstetrical practices during birth; she noted many were frightened or shy or simply too reticent to talk. Others played the blame game; “I never had a woman with childbed fever–but Mrs. K. has ’em.” “I never lost a woman but Aunt Nora has lost three”–“I never sent for a doctor yit, but Beck has to send for ’em”- and so on. Additionally, the midwives were very vocal about not needing to send for a doctor. Only eighteen spoke as if they ever recognized the need for medical assistance in any but cases exceptional as to stand out above the rest. Sometimes sending for a doctor or pseudo-doctor were geographically or cost-prohibitive. Only seven of the midwives had ever seen forceps applied.
Seven of the midwives had had a doctor or pseudo-doctor to “get an afterbirth that had ‘growed to the womb'” or because “the baby was dead, and had growed to her backbone, and the doctor had to put her to sleep and pull it loose.” Another midwife talked of a mother who was having “fits;” a total of thirteen before the doctor arrived, both baby and mother survived. Age was a factor for many of these midwives, but not in the way one might think looking through a modern lens. One claimed that the mother was “right old” and her age? She had just turned twenty-two. Another midwife had a mother of similar age who she referred to as an “old girl.” The midwife made clear that girls of sixteen or seventeen “don’t have much trouble” but a woman of twenty-two has “settled by that time.”
Midwives often delivered their grandchildren. One thought back to her daughter who had died a few days following childbirth because she could not get the afterbirth. She called a pseudo-doctor who “‘pinched off the cord’ instead of ‘peeling hit’–and so ‘mortified’ her daughter that she died.” All of the midwives made examinations with greased hands. “One described reaching into the uterus to grease the baby’s shoulder.” When the midwives were asked if they washed their hands, some of the replied, “cou’se I don’t wash ’em–I greases ’em.” Most, however, said they washed their hands first with potash soap not lye soap. One midwife noted that she “used a towel and lard and had her hands ‘like I was goin’ to make up a mess of biscuits.” Surprisingly, Mary noted that there were only a scant few cases of reported childbed fever in 1922 for the counties she visited.
Mary noted, “rarely ever did I feel that the statements given me regarding maternal deaths and stillbirths were accurate.” Many of the midwives claimed the “never lost a mother or child.” Where others claimed that “upwards of a thousand deliveries, she had only lost two mothers.” Still yet, some would “figger” that they had one or two stillbirths, some lost “nary a mother.” Placenta issues were also a problem, though most of the midwives played it down. Several said they would “reach for them and they just come out.” Another mentioned that the afterbirth was stuck and she “pulled them out as good as anybody.” Yet another noted that she only had to go in after one. That was with a woman where the baby and everything had “rotted,” and came out in pieces.
A common expression from the midwives was, “always been blessed with good luck.” Additionally, “one dirty old soul in Knott County told me she “took the Lord with her” and that was why she had such good luck. It was nearly a “universal” practice among the older midwives to deliver women sitting on someone’s knees, usually the patient’s husband–“her man.” Two preferred the woman to sit on a chair without a seat and one said she sometimes had the mother stand up. “Perhaps the expression “catching the baby” arises from this custom.”
Placenta previa appeared to be an issue; one of the local doctors told Mary that he had been called in for seven of these cases in only a few years. The midwives were wholly unprepared for issues like this. Hemorrhage was the most frequent issue. Only three midwives knew how to hold the fundus. One in Knott County said, “raise her hips and stuff her with cotton.” Though she never tried this method. Another custom, albeit sparsely used at that point, was cording the leg; some specified the left leg and hand, one mentioned the left leg and arm, and another the right leg. Another midwife said she found most useful a bible verse, Ezekiel 16:6, “And when I passed by thee, I saw thee polluted in thine own blood. I said unto thee when thou wast polluted in thine own blood, live. Yea, I said unto thee when thou wast in thy blood, live.” This she said she had also tried successfully on a dehorned steer which was bleeding to death.
Remedies for hemorrhages were homemade. A couple of the midwives recommended ergot while one recommended a paregoric, and yet another said laudanum, though it was not accessibly by that point. She recommended as substitute several cold cloths applied locally. A tea to ward off miscarriages could be made of “black gum bark mixed with sweet apple tree bark, and peeled one piece up and one piece down.” These were also recommended by several for severe bleeding. A midwife in Owsley said to use black hum bark from the north side of the tree mixed with the bark of a sweet apple tree. Yellow root tea, rattleweed, root, sarvice bark tea, “comfrey” roots, pepper tea, asafetida, nutmeg, and the leaves of a white pine in a tea were all various solutions recommended by the mountain midwives. Others included chimney, coal, and wood soot and a variety of spices eaten “just so.” One rather interesting superstition was putting an ax under the bed, blade up, to stop a hemorrhage.
For protracted or retarded labor, pepper tea, red or black, was a very popular solution. Black gum bark, roots of the rattleweed, blueberry, raspberry, yellow spicewood, and bluebell were solutions given by way of tea. “Witch hazel bark boiled into a thick syrup,” ginger, tea, tansy, peppermint, burvine, sulphur in sugar, quinine and gunpowder were all approaches. To induce labor or “miseries” some midwives would administer a tea made from rattleweed root. For afterpains, some used angelico root, elecampane, and “a yarb that grows low down on the branches.”
Most of the babies were dosed castor oil, some also added catnip tea as well, and some gave sugared milk (as well as to the mother). All cut the cord with unboiled scissors and would ligate it with several strands of thread twisted together. Most greased the navel with lard or castor oil and then put a scorched rag over it. To revive a baby, some would “work its arms and legs” but most put it in water. One “floats hit in cold water” while one would “wash its breast” and yet another would “wash hit in camphor.”
Prenatal and postnatal care were essentially non-existent for women in the mountains. There was generally a confinement period briefly before birth but mothers often did extreme work (e.g. farming or sawing wood in all seasons). Additionally, mothers were out of bed within three or four days of giving birth. Women who had given birth multiple times often dealt with a “fallin’ womb” or a prolapsed uterus.
Contributed by Shawn Logan | contact@kyhi.org
⁘ Works Cited ⁘
- Mary Breckinridge, “Midwifery in the Kentucky Mountains: An Investigation in 1923,” The Frontier Nursing Service Quarterly Bulletin, XVII (Spring 1942), 37
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