The Black Birthing Body
A look into midwifery and Black maternal and child healthcare in the United States
History of Black Midwifery in the United States
Black midwifery can be traced back to West Africa where midwifery is a part of the culture. The tradition holds that the birth giver would be surrounded by their female relatives who would act as the midwife. Midwifery in West Africa has spiritual undertones relating to nature and the earth. Midwives are prominent members of the community. They do more than just deliver babies, they are spiritual healers in the way that they act as family counselors, nutritionists, postpartum doulas, the go-to people for resources.
In the 17th century, during the Atlantic Slave Trade, this tradition was brought to the United States. “Granny” or “grand” midwives (though there is controversy with these titles today), were typically older women who took over this tradition. Most plantations designated women who attended births of both enslaved women and slave owners’ wives/mistresses and cared for the babies as they grew up. After emancipation, many continued to do birth work in their communities. With no formal medical training or education. the tradition of midwifery was passed down the generations through apprenticeship. By the end of the 19th century and the beginning of the 20th, approximately 50% of all births were attended by midwives.
The 20th century marked the development of reproductive health care. The obstetrics field was becoming more medicalized and professionalized. Women started to go to doctors seeking a less painful birthing experience than at home. Doctors also began pushing midwives out of the field by creating propaganda against the “unnatural ways of childbirth”, which midwifery promoted. This propaganda was mostly directed at the black midwives; it called them “unclean, folksy “granny.”
Even though this defamation and racism were occurring, black midwives continued to practice. Midwifery began to make a comeback in the 1970s and 80s, embraced by middle-class white women who wanted more of a voice in their maternity care, including the possibility of delivering at home. Though the ethnic makeup of midwifery has changed over time, it is thanks to strong black women who fought for the right to practice midwifery such as Margaret Charles Smith, Mary Coley, and Ms. Arilla Smiley that the practice is what it is today.
The current state of midwifery
Midwifery in the United States is a complex field. Over the years different types of midwives have emerged. These include traditional midwives, certified nurse-midwives (CNM), and direct-entry midwives which consist of certified midwives (CM), certified professional midwives (CPM). Each type of midwife has unique qualifications and requirements. The CNM has a degree in nursing while also training in midwifery and they are typically based out of a hospital or clinic. The CM has a bachelor’s degree in another health-related field that isn’t nursing while also having training in midwifery.
The CPM only has training in midwifery and is typically based in birth centers and homes. CNMs typically work in hospitals while sometimes (rarely) they will work at a birth center or perform home births, CMs perform in similar places as the CNM, and CPMs typically conduct home births or work at birthing centers.
According to the American Midwifery Certification Board, there were 11,826 CNMs and 101 CMs in 2017. While searching for information for this paper I noticed that there is a serious lack of contemporary information regarding Black midwives and midwives of color in general. And the little information that I could find about Black midwives was only about Black CNMs. The American College of Nurse-Midwives says that as of 2018 “midwives of color represent 5%-6% of ACNM midwives ”and 2% of all midwives in the U.S. are Black.
The laws and regulations regarding midwives vary drastically throughout the country. CNMs are legally allowed to practice in every state in the country and the District of Columbia. The direct-entry midwives have more restrictions placed on them regarding practicing due to the difference in qualifications from the CNMs. CMs are only legally allowed to practice in New York, New Jersey, Rhode Island, Delaware, Maine, and Missouri. The title of CPM is more complicated. According to the MANA, CPMs have national certification through the North American Registry of Midwives but there is no set national licensing for them. Each state has separate rules and regulations for the CPM. Due to this, the CPMs are legally allowed to practice in 30 states, while 11 states have pending legislation, 4 states are planning legislation, and 5 states are advocating for legislation.
How Can Midwifery Help the Black Community?
The United States spends 18% of the GDP on health care ($3.5 trillion), two times the average of other developed countries, yet it has some of the worse health statistics in the world. There is a disproportionately low distribution of resources to racial/ethnic communities. The healthcare system tends to favor white people over minorities. Black birth givers and babies have significantly worse birth outcomes compared to their white counterparts, and even the US average overall.
According to the National Center for Health Statistics, the U.S is number 27 in infant mortality rate (IMR) among all industrialized countries. In 2016 the IMR was 5.9 deaths per 1,000 live births. Black birth givers are three to four times more likely to die in pregnancy or childbirth than their white counterparts; black babies are 49 percent more likely to be born prematurely and twice as likely to perish before their first birthdays.
In a five-year research project conducted by researchers in Canada and the U.S., it was found that states that incorporate midwives into their health care system have better birth outcomes for birth givers and babies, while on the other hand, states that place more restrictions on midwives have worse outcomes.
The states that typically have more restrictive regulations and laws are Southern states. In a 2015 article by Hirai et al., it was stated that in the 1980s “72% of the excess infant mortality in the South was due to the greater proportion of Black births, reflecting a persistent racial disparity. According to a map published by Birth Place Lab in 2016, this pattern still holds constant today. In 2013 the cesarean section rate in the US was 32%, while the rate in Black women was greater at 35.8%.
These health complications among Black birth givers are due to the lack of qualified maternal care, either from an absence of practicing OB/GYNs or discrimination, most of the time both. Black women typically go to certain hospitals where they tend to deliver a disproportionate number of Black babies. They are sometimes called “black-serving” hospitals. The “black serving” hospitals have higher rates of birthing complications such as infections, hemorrhaging, and emergency hysterectomies. These sets of hospitals are
“more likely to provide lower quality of care compared to hospitals where White women deliver. Unconscious biases are prevalent throughout the medical system, impacting how medical professionals perceive and respond to Black compared to White patients’ pain”.
Today less than 10% of births in the US are attended by midwives, compared to other countries where midwives attend >50% of births. One reason for this might be due to economic and regulatory barriers that these midwives must face such as “inability to secure third party reimbursement” and laws restricting midwives. These barriers make it hard for people to use midwives in their birthing process. Neel Shah, an assistant professor at Harvard Medical School and activist to reduce C-sections, believes that midwives are a useful component to solving the shortage of maternity care in the minority and low-income communities. This is sadly an unfortunate chain of events because midwifery can be exceptionally useful in decreasing the health disparities in the US.
The Midwives Alliance of North America follows the Midwives Model of Careto ensure the best and safest overall experience for the birth giver. The Midwives Model of Care consists of educating, counseling, and monitoring the birth giver throughout the whole pregnancy, providing pre- and postnatal care and support, assisting during labor and delivery, and using minimal technological interventions except when necessary. This model of care encourages “community-based care, close relationships between provider and patients, prenatal and postpartum wellness, and avoiding unnecessary interventions…” (Martin). A study by Homer et al. concluded that midwifery could help avert 83% of all maternal deaths, stillbirths, and neonatal deaths.
Changes to the Midwifery Structure
Before midwifery can spread through communities, there needs to be a drastic change from the inside. In the midwifery community and the healthcare system, there is discrimination and systemic racism which shapes the way that minority groups are treated. There is an appalling lack of diversity in the midwifery community. While 45.6% of the people who use midwives are non-white, only 12% of midwives are non-white. The number of midwives of color doesn’t adequately represent the population of people they are treating. Not only that, but there is also a lack of a voice from those who are underrepresented in midwifery. The core value of midwifery is to be empathetic, understanding, caring, and a listener. Though this may be shown to the birthing people, this isn’t shown to fellow midwives.
In a 2014 dissertation by Keisha L. Goode at NYU, a study of 22 black midwives (12 CNMs and 10 CPMs) aged 20–80 was conducted. In this study, the women were interviewed about their experiences being black midwife and their views on the midwifery field considering the national data regarding the IMR and MMR. Goode discusses the experiences that these Black midwives have had within the field of midwifery, specifically associating with MANA and ACNM. The oldest participant, around 80 years old, mentioned how they used to go to meetings but eventually stopped because they were “fed up because there was not a lot of attention to race and, to be honest, it was racist”.
These women feel silenced, unheard, underappreciated, undervalued, and overall disrespected. These have been consistent and pressing issues for many years, and nothing has been changed and no one, except for the Black women who it is affecting, seems to care. Despite the Midwives of Color (MOC) Section of MANA, the presence of institutionalized racism was overbearing. It caused for the resignation of six members, including the chair, of the MOC section, who noted in the resignation letter,
“repeated exposure to discrimination and racist attitudes — whether intentional or out of ignorance — is oppressive and not good for them mentally, physically, emotionally, and psychologically. ”
Race and ethnicity go deeper than the color of one’s skin. It plays an integral part in their core values and culture. The understanding of this concept is something that needs to be learned by the greater midwifery community, not just MANA, and ACNM. Midwifery can have a significant impact in decreasing the horrendous birth outcome rates in the black community when it is utilized correctly, but first, these issues must be addressed. This involves recruiting more midwifery teachers and advisors of color and developing more “ethnic-specific” care.
Faculty and advisors are people that you can go to for help and guide you. Having an advisor that looks like you builds a level of comfort knowing that they may have had similar experiences as you because of how they look. A lack of diversity can lead to culturally inappropriate treatment. A more diverse teaching environment allows for more diverse education.
Midwives of color “can relate to the cultural backgrounds of minority patients and provide culturally appropriate care that is sensitive to their needs”. Incorporating teachers and advisors that have varying races and ethnicities and are from a broader range of cultures makes it easier to learn about the many cultural experiences in a non-stereotypical/non-discriminatory way. Allowing them to gain real-life knowledge and experience about what they may be presented with in the outside world and one day may have to integrate into their practice.
The United States is one of the most racially, ethnically, and culturally rich countries in the world. Culture is in everything and it is everywhere. It affects all our actions, behaviors, emotions, what we eat, and more. Childbirth is one of the most important moments of someone’s life. Being able to make that moment special for them is an amazing opportunity that not many people have. Most people choose midwives because of the personal and individual care that comes along with it. Being aware of the patient’s culture shows respect and support which helps build trust, which is a necessity when it comes to midwifery. There needs to be an emphasis on values including “respect, communication, community knowledge and understanding, and care tailored to a woman’s circumstances and needs”. This quote given by a black midwife in Goode’s dissertation stood out to me,
“I had a diverse group of women I worked with…in terms of race. When I see another black woman giving birth…you know, when I am there with her…I know her and can relate to her like I can’t other women… I know how it feels to be a black woman in this world…walking down the street, at work. Stupid stuff people say. The way stuff makes you feel. That small stuff. I also know what it feels like to be a black mother in this world. I know what we been through as people and what that means for her and her baby. We are a strong, smart, prideful people but it’s hard. And I know them…I know her”.
To end this article, it is essential to mention that race is the primary component of this inadequate care of Black women. I am not trying to negate the fact that socioeconomic status and education also play a component, but it all comes down to race. Prominent Black figures such as Serena Williams and Beyoncé have both shared their traumatic stories about giving birth to their children. Both women are successful, both women are wealthy, and both women are Black. Midwifery can have a significant impact on decreasing birthing complications. The only way to change these tragic statics is a systematic change in both midwifery and the healthcare system.
