Regulating Midwifery Through Manuals: Institutionalization and the Displacement of Traditional Midwives in the...

Efforts to standardize perinatal care in the early-mid 20th century led to the development of standardized midwifery training manuals produced by the US Children's Bureau and adapted by state health departments. This analysis examines how these manuals facilitated the institutionalization of midwifery education and contributed to the displacement of apprentice-trained Indigenous and Black midwives. Primary-source manuals from the US Children's Bureau and the Alabama and Mississippi departments of public health were examined through direct visual analysis, including a reproduced copy of the Alabama manual. Manuals were selected based on their publication following the Sheppard-Towner Maternity and Infancy Act, their documented use in state-supported programs, and the completeness of available editions. A comparative historical framework, informed by public health history and institutionalization theory, guided interpretation. The manuals codified competencies, literacy and documentation requirements, and supervisory oversight, shifting authority from community midwives to state-approved professionals. Alabama's implementation illustrates how federal guidance was operationalized locally through eligibility standards, record-keeping practices, inspections, and narrowing pathways into practice, measures that selectively advantage nurse-led models. Beyond procedural standardization, the manuals embedded racialized and classed assumptions, framing traditional midwives as problems to be corrected rather than knowledge-holders. These dynamics aligned with broader regulatory campaigns that restricted licensure, increased surveillance, and ultimately diminished traditional midwifery practice. Midwifery training manuals consequently functioned not only as instructional texts but also as tools of institutionalization that reshaped who was permitted to practice, under what authority, and to whose benefit. Understanding this history clarifies contemporary debates surrounding regulation, equity, and authority in midwifery care.