End Racial Disparities in Maternal Health, Call a Midwife

February 2, 2020

For Black women, New York City is one of the scariest places one could give birth. Black women in New York City are eight times more likely to die from pregnancy-related complications than white women. In central Brooklyn, a predominately Black area with the city’s highest rates of maternal mortality and morbidity, the nearest hospitals rank worst in the city for maternal harm. For Black women the message is clear: New York’s public hospital system can be dangerous to your health.

Many Americans have no idea that midwives and birthing centers offer safer alternatives. Until the 20th century, most women delivered with Black and immigrant midwives, who modeled patient-centered care before the term even existed; but since then midwifery has been systematically discredited. It is high time that we restore this profession. 

Before the 20th century, midwives were community-based healthcare providers with intimate knowledge of birth processes and strong relationships with their clients. As the nascent medical profession gained stamina with the advent of surgery and handwashing, doctors—predominately white men—openly advocated for midwives’ disappearance. By the early 1900s, the movement to delegitimize midwifery rose alongside immigrant quotas and Jim Crow laws. Physicians and health officials across the country published articles linking midwifery to high rates of infant and maternal mortality, blaming Eastern European and Black women for public health emergencies with the same arguments used to blame immigrants for diseases caused by overcrowding and poor sanitation: “illiteracy, carelessness and general filth.” In 1921, Congress passed the Sheppard-Towner Act requiring all midwives to undergo health safety training. Although the bill aimed to minimize lethal maternal health risks, advocates mapped race and ethnicity onto hygiene and inadequate healthcare systems, molding the midwife’s image into that of a racist caricature. As a result, midwives were banned from hospitals, and by 1951, 90 percent of women gave birth in hospitals.

Midwifery has the potential to bridge gaps in care and reduce disparities through its commitment to women and reproductive health.

Racial disparities in maternal mortality and morbidity are not new, inexplicable phenomena. Their rise has partially been the byproduct of a methodical attempt to shut minority women out of a professional field. Research has proven that racial and ethnic representation among healthcare providers is critical to improving health outcomes for minority populations. Some suggest we increase Black women’s matriculation through medical school, but today they comprise 11 percent of American OB/GYNs—a number nearly proportionate to the Black population in America. Others tout cultural competence training in medical school matriculation as an easy fix. These solutions are working toward the right goals, but the overall healthcare system is inadequate, and Black women disproportionately struggle to access care in the first place. The United States faces a nationwide shortage of maternal healthcare providers. Doctors perform critical, lifesaving procedures for many pregnant women, but for those in states like Georgia where 79 counties lack an OB/GYN, a midwife might be the difference between life and death. Representation and implicit bias courses are wholly insufficient to fix a national crisis.

Midwifery has the potential to bridge gaps in care and reduce disparities through its commitment to women and reproductive health. A healthy body of research shows that implementing midwifery on a grand scale can lower rates of pregnancy-related complications and maternal and infant mortality. Clients who birth with midwives report a greater satisfaction of care and higher incidence and prevalence of breastfeeding. This is all due to the framework of care under which midwives operate.

Midwives view reproductive health as both clinical and social justice. An Indiana University study revealed that Black midwives are committed to reproductive justice as part of their care models. Midwives provide much-needed education on the birthing process and client’s options, promoting bodily autonomy and agency as a top priority. Advocacy for racial justice and reproductive health on behalf of their clients to change social policy and create opportunities for the communities they serve is a key part of their role. Midwives view equity and equality as imperative to health.

Reducing racial inequity in maternal health needs to advance beyond weathering and listening to Black women. We need to integrate midwives as part of birthing teams, attending births alongside obstetricians. In collaboration with the American College of Nurse-Midwives, the American College of Obstetricians and Gynecologist released a joint statement supporting “team-based care,” and some hospitals like Yale New Haven Hospital employ midwives who operate within hospitals attending successful births and functioning as part of the maternity services staff. Models like these are commonplace globally, but the United States has yet to catch up. Restoring the state of midwifery is arguably a matter of life and death and requires pregnant persons, their partners and families to tell their stories publicly, to pressure lawmakers to expand state licensure, establish Medicaid reimbursement, and accredit midwifery schools. Midwives advocate for us, so let’s advocate for them.

Kennedy Austin is a 2021 MPH degree candidate in the Department of Sociomedical Sciences. She became interested in midwifery as a means to address racial disparities in reproductive healthcare when Governor Cuomo announced Medicaid reimbursement for doula care last year. 

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