Kiki Jordan, a Certified Professional Midwife in Oakland, California, sees the realities of the maternal health crisis among women of color every day.
“You see Black women who are more affluent, more educated, maybe in partnership. Maybe she has all the resources,” she said. “These Black women are still having the same devastating birth outcomes.”
Black and Indigenous women in the United States are two to three times more likely to die from a pregnancy-related cause than white women, even when controlling for socioeconomic factors, such as income and education.
The reason, according to Jordan, is racism: “I think why there’s so much Black maternal mortality and morbidity in our country because of generational trauma around race.”
As a Black midwife, Jordan says maternal health care that prioritizes the social and emotional health of patients could improve birth outcomes for women of color in the United States: “My belief is that this model of midwifery care…can help to heal that generational trauma if people are getting loved on during their pregnancy and birth.”
Understanding the benefits of midwifery and the importance of racially concordant care, Direct Relief has partnered with the National Association of Certified Professional Midwives to provide $50,000 in funding to support Black and Indigenous midwifery students in the United States. The funds will be used to assist with the cost of tuition, licensing, exam fees, and mentorship.
Addressing the Legacy of Racism
According to a seminal study published in the American Journal of Public Health, experiencing racism over a lifetime produces sustained levels of cortisol that cause body systems to break down more quickly. The phenomenon, known as the “weathering effect,” has been posited as one of the causes of racial health inequities in the United States, including disproportionately high rates of chronic disease among people of color.
“Black women tend to enter pregnancy with pre-existing conditions,” said Jamarah Amani, a certified professional midwife and co-founder of the National Black Midwives Alliance. “If those are not being addressed prior to the pregnancy, then in pregnancy, they will skyrocket because of the stress that pregnancy puts on the body.”
The hypothesis that inequities in maternal mortality are not simply a matter of cultural or socioeconomic factors is further supported by research showing that African- and Caribbean-born women living in the United States have the same birth outcomes as white women, despite sharing the same ethnic backgrounds as Black Americans.
“It’s not a genetic marker. It’s not a socioeconomic issue. This is really about exposure to racism over the course of someone’s life. So it’s racism, not race, that is at the root of these disparities,” said Amani.
While an extensive body of research disentangles the relationship between racism and poor health outcomes, for Amani, a Black woman, racism and its effects are “embedded.”
“You can’t measure it. You don’t know necessarily when or how or what the trigger is going to be or how it’s going to affect you. You may not be able to ever articulate what that thing was that spiked your blood pressure or what that thing was that made you depressed…That is…the visceral kind of way that oppression and racism embed themselves into our bodies,” she said.
The Midwifery Model
Midwives serve as the primary point of contact for many women throughout their pregnancy and postpartum experience. They perform routine prenatal check-ups, attend the birth, and provide postpartum care. Many midwives serve as women’s primary health care providers beyond their birthing years. This differs from conventional models in which women have a primary obstetrician but are seen by different nurse practitioners for most routine visits, according to Jordan.
Midwifery-led care has been shown to improve health outcomes among birthing women worldwide, leading to lower rates of cesarean sections, preterm births, and anemia. The World Health Organization has identified midwifery as playing a “vital” role in lowering global maternal and newborn mortality.
At Amani’s midwifery practice in Florida, for example, addressing common diet deficiencies such as anemia usually involves a comprehensive care strategy. “Instead of just being like, take this pill for iron, we sit down and make a plan.” She reviews patients’ diets and helps them determine ways to get more iron-rich foods in their diets, and provides recipe ideas that are nutrient-rich and inexpensive. If it’s a transportation issue, she helps patients navigate the public bus or organize rides with family members to and from the grocery store. She’s even ordered Ubers for those who “just don’t have any resources or support.”
Improving maternal health outcomes “really does require more time, attention, knowledge and care, and those are hallmarks of how midwives do what we do,” she said.
A legacy of medical mistreatment
While midwifery-led care has been shown to improve outcomes for women globally, it could be particularly beneficial for women of color in the United States. According to a study published in the National Library of Medicine, Black and indigenous Americans report lower levels of trust in the healthcare system due to decades of mistreatment and abuse by healthcare providers.
Jordan says this has led to an increase in demand for her midwifery services, which are provided outside of a hospital setting: “What I’m seeing in my personal practice is that more people of color, more people from marginalized communities are looking into alternative birth options.”
This was particularly apparent after the murder of George Floyd in 2020, she said, which led to a wave of social justice protests and increased public awareness of the Black maternal health crisis.
Cost: “A Huge Barrier”
Despite midwifery being an attractive alternative for Black and Indigenous mothers, they often have the hardest time accessing it. “The biggest barrier to accessing midwifery is just the cost,” said Amani.
Black and Latino Americans are two times more likely to be poor than their white and Asian counterparts, according to an analysis of 2019 U.S. Census data. For Indigenous Americans, poverty rates are up to three times higher.
And, in most states, midwifery care isn’t covered by Medicaid—the public insurance for low-income Americans. “That’s a huge barrier for low
-income folks who want to access this type of midwifery care,” said Jordan.
As a result, women of color are less likely to be cared for by a midwife during their pregnancy. According to an analysis of CDC data, white women in the United States are two and 3.5 times more likely to have a midwife than Latina and Black women, respectively.
These economic barriers motivated Jordan to establish a birth center that accepts government insurance. Her birth center is part of a federally qualified health center, making it eligible for government reimbursement.
Jordan was 20 years old and eight months pregnant when she opted to hire a midwife. She made payments to afford the services.
“It was challenging for me to access it,” said Jordan. “Why would I create a practice where people couldn’t afford my services?”
Today, her birth center in California’s Bay Area provides midwifery care at little to no cost to low-income women who are uninsured or underinsured.
However, laws differ by state, and most don’t allow midwives to bill Medicaid. As a result, midwives are less likely to care for women of color, and the profession itself is lacking in diversity: Nearly 90% of certified nurse-midwives are white.
For mothers of color, this is a problem. “We know that concordant care really matters. That if I’m being cared for by somebody who understands me culturally, looks like me…that improves how I understand the care that I’m receiving, how I experience it, and it improves physiological outcomes,” said Dr. Keisha Goode, a midwife, vice president of the National Association of Certified Midwives, and professor of sociology at SUNY Old Westbury.
A large body of research shows mothers who share the same race as their provider report higher levels of trust and comfortability with their doctor and give birth to healthier babies. One recent study found mortality rates among Black newborns were cut in half when care was provided by a Black physician.
“Black midwives and Indigenous midwives have literally birthed the nation.”
While today a majority of midwives and the patients they serve are white, the practice has deep roots in Black culture. ¨Well, up until the 1950s, there were Black midwives who were providing the majority of care,” explained Goode. Before the rise of obstetrics, midwifery was the dominant model of care, and all women typically gave birth at home.
“Black midwives and Indigenous midwives have literally birthed the nation. And in our understanding of American history, midwifery has not been paid proper due,” said Goode. Before the Civil War, the majority of births in the Southern United States were attended by enslaved African women and their descendants.
The change in the demographic makeup of midwifery is often traced back to the Shepherd Towners Act of 1921. The act was implemented to reduce infant and maternal mortality in the United States and created a system of training and licensure for midwives who had learned their practice through long-term apprenticeship for centuries.
While the midwifery training courses introduced new techniques on sanitation that helped save lives, they also created barriers to entering the midwifery workforce. To obtain a license, midwives often had to pay a fee and travel distances to attend regular courses—which rural, low-income midwives couldn’t afford. “You can’t say everybody has to be licensed without also providing equitable avenues for people to be licensed, so sometimes laws and policies get used as a way of exclusion,” said Goode. As a result, “those midwifery practices or midwives themselves either passed on or were unable to practice.”
Between 1910 and 1930, the number of births attended by a midwife dropped from 50% to 15%, according to a CDC report, while hospital births increased in tandem. Today, only about 10% of births in the United States today are attended by a midwife.
“The cornerstone of direct entry midwifery is that it’s personalized. It’s about building relationships and working in partnership with your client, and so that’s much easier to do if your midwife shares a similar lived experience,” said Jordan.
While midwifery-led care alone is unlikely to solve the maternal health crisis, said Goode, care that reflects the patient is fundamental: “It is not that having a Black midwife caring for a Black person eliminates racism. That is not at all what I’m saying. But that kind of care, being cared and loved by somebody who looks like you, knows you, understands you culturally, is so incredibly important.”