Home birth is not a luxury. Midwives are not a status symbol, and doulas are not trendy.
All three are rooted in cultural practices that have existed long before modern maternity care. For centuries, women have been supported by their families during pregnancy and childbirth.
My grandmother birthed most of her children at home with a midwife in the Dominican Republic.
When my mom was pregnant with me, my grandmother cooked her meals, and my aunts checked in on her frequently. My mother was not alone when it came time for labor and delivery. Her oldest sister was with her, helping her through every contraction until I was born into the hands of a hospital-based midwife.
My family resembles countless others in the global diaspora who have familial ties to midwifery traditions that hail from the Caribbean, Central and South America, indigenous and African cultures. The United States used to rely on these practices. At the beginning of the 20th century, 50 percent of all babies were born into the hands of a midwife, according to the International Center for Traditional Childbearing. Many of these midwives were African Americans.
The advent of hospital-based birth during the 1900s changed everything, producing a historical amnesia. Women were convinced that midwives were unfit to provide the very care they had provided for centuries due to intentional propaganda against "black granny” midwives.
Today, most women in the United States give birth in hospitals with the help of doctors. In 2015, 98.5 percent of all births occurred in hospitals. Of those births, 8.1 percent were attended by certified nurse midwives (CNM) and/or certified midwives (CM).
However, a growing number of women are leaving hospitals behind, choosing to deliver their babies at home or at a birthing center instead. There were 61,041 out-of-hospital births in 2015. A majority of women who chose this option were white.
As a trained doula and certified professional midwife, I applaud that they made a choice that works for them. But as a birth justice activist who works in the Bronx, N.Y., I find that this data only reinforces what I know to be true: Marginalized women and individuals in the United States do not have equitable access to options outside of hospital birth.
The natural birth movement has been spearheaded by white middle- to upper-class women, as described in “Birthing Justice,” a book about black women, pregnancy and childbirth. White women’s efforts have re-popularized the idea of using a midwife or doula, and they’ve managed to make natural births mainstream. But they are not addressing the needs of marginalized women, who could be minorities, immigrants, low-income, transgender or gender non-conforming.
In some ways, the health-care industry is putting up barriers between these women and their cultural traditions by making it expensive and inconvenient for them to access a range of birthing options.
And, at a certain point, it goes beyond cultural importance. We’re searching for ways to reduce the country’s maternal mortality and morbidity rates – black mothers in the United States die at three to four times the rate of white mothers – and doulas and midwives are one solution. Yet it’s harder for black women and other marginalized people to access these services.
Barriers for marginalized women preparing to give birth
Under the Affordable Care Act in 2014, health insurance became mandatory for pregnancy, labor and childbirth, as well as newborn care. However, insurance companies have varying policies for home births. From my experience, many home birth midwives are considered out of network providers, meaning insurance companies get to decide how much they will pay based on their out-of-network policy. Medicaid tends to pay the least for home births. Some midwives are willing to work for whatever the insurance company will pay, but it can be challenging to find a midwife who can afford to take on these clients.
For marginalized individuals, adequate care is characterized not only by quality and quantity but also a culturally relevant health-care provider. Marginalized women are more likely to be low-income and therefore more likely to be uninsured. Additionally, hospitals and clinics serving low-income communities are often overcrowded and understaffed. Understaffing can create pressure to care for a high volume of patients, making it difficult or impossible to provide quality care.
There is one more barrier that must be taken into account: systemic racism.
The racism that black and other marginalized women deal with on a daily basis is pervasive. Implicit bias affects the way marginalized people are treated when they access health care, and they suffer as a result, either from neglect or abusive healthcare environments.
Overcoming these barriers can lead to better birth outcomes
This year, a study concluded that the integration of midwives into the health-care system contribute to improved birth outcomes. The use of a midwife is linked to lower rates of preterm births, and they are less likely to perform a Cesarean section.
But states with high rates of black births had the least integrated systems, meaning there were fewer midwives and fewer options for community birth. Increased access to these services could reduce pregnancy-related complications.
Studies have also shown that women who have continuous support during labor are more likely to have spontaneous vaginal births and less likely to need interventions, such as epidurals, forceps or a Cesarean birth. While these steps are sometimes necessary to protect the mother and child, fewer interventions can reduce morbidity and mortality.
Additionally, continuous support like a doula during pregnancy, childbirth and the postpartum period provides the birthing individual with a person who will support them in advocating for the care they need.
The benefits of home birth
Given the long history of experimentation and past/present trauma African American and marginalized women have suffered with the advent of the modern American medical system, home birth can provide a psychologically safe environment that could be less traumatic.
The benefits to marginalized women accessing home birth also include a reclaiming of their cultural and ethnic legacy. Reconnecting with home birth and a holistic approach to maternity care allows women to gain a deeper trust of themselves and their bodies. They become an active participant in their care due to the client-centered model of midwifery. For births that are safer in hospitals due to preexisting or developing medical conditions, the co-management of a woman’s care with a midwife and team of specialized medical professionals can contribute to the woman’s overall emotional and mental health while not sacrificing safety.
Resources and solutions
Solutions to the maternal health crisis exist, and many doulas and midwives are answering the call to change systemic issues in the birthing process. Although marginalized women face certain barriers in accessing this care, I believe they can overcome them with the right guidance and information.
• Yes, there are some doulas who are expensive. But there are also organizations, such as Ancient Song Doula Services in New York City, that are committed to assisting women in finding affordable doula care.
• If you want a home birth, insurance can be another obstacle. To circumvent this issue, reach out to midwives to see what their options are, such as payment plans and negotiating compensation in some cases. There are midwives who are willing to work with people on Medicaid.
• Get informed by looking for childbirth education classes. Classes taught by independent childbirth educators are full of information on how to best manage birth, unmedicated or otherwise. I would also suggest looking to local libraries, community clinics and yoga studios for more information about positive birthing experiences.
• Find support. Ultimately, the restoration of community ties and unity is paramount to the reconstruction of optimal maternal health. Tap into gathering places in beauty salons, daycare centers, schools churches and online communities.