How can midwifery truly be made accessible to communities of color?

Right as 2011 was wrapping up two articles were posted about home birth and midwifery revivals in communities of color. Having written about the question of race in the home birth movement back in 2009 for RH Reality Check in these two articles, I’m excited when new outlets pick up the story. There is much movement in this arena, and also much more than can be done to make sure US midwifery is accessible to people of color.

In New America Media, Valeria Fernandez writes about efforts to revive Mexican midwifery in Arizona:

Marinah Valenzuela Farrell is one of only a few licensed midwives in Arizona. Though it isn’t a profitable venture, helping mothers bring their newborn children into this world is for Farrell a calling deeply rooted in her native Mexican tradition.

“It is really hard to be a midwife,” said the 41-year-old. “You don’t sleep, and you don’t make money. People think you’re crazy because you’re doing homebirths.”

A majority of Farrell’s clients are middle class and white, though as a Latina she aims to make midwifery accessible to low-income women in dire need of prenatal services but too afraid to seek them out in a state virulently hostile to undocumented immigrants.

“I think they don’t know that we exist,” she said. “I think the more the community knows that there’s a midwife who will come and visit them at home and do a homebirth… [attitudes] will change and shift.”

I spoke to the author while she was working on the piece, and a quote of mine is included toward the end.

In The Grio, Chika Oduah writes about black women and home birth. The article includes a video, which is a good primer of the issues at hand with home birth. It also references my Colorlines article about the possible connection between maternal health in communities of color and access to midwifery care.

What is clear from the research about this issue is that women of color are less likely to receive midwifery care, and that disparity is larger than the population numbers would suggest. I think this dynamic is complicated by global sociopolitical historical factors. For example I experienced resistance from Latina immigrant women to midwifery care because of the stigma toward parteras (midwives) in their home countries. In many places in Latin America, midwives and home birth are seen as the option used by women who can’t afford to go to hospital for birth–basically an option only for those who have no other option.

That creates class and race stigma on home birth and midwifery care.

This stigma is no accident. Global socioeconomic policy in Latin America (and I assume elsewhere as well) has long promoted hospital-based childbirth as a marker of development, and encouraged this move with foreign aid dollars and other development initiatives. The medical students I observed in Ecuador were clear that their obstetrical training and guidance came from US practice. So does the push toward hospital-based birth and away from traditional midwifery care.

We cannot ignore the fact that lack of access to emergency obstetrical care and trained birth attendants does lead to increased maternal and infant mortality. But we must also acknowledge what is lost and what new risks emerge when the model is pushed wholly toward medicalized hospital based care. Example: the United States. 98% of births happen in hospitals in the US, but our maternal and infant mortality rates are a serious concern, and lag behind 48 other countries. Clearly simply moving birth from home to hospital does not solve infant or maternal mortality.

I digress a bit, but the ultimate point is this stigma comes with immigrant women, and influences the choices they might make when it comes to maternity care in the US.

With African American folks who might not be recent immigrants, there is another factor at play. Claudia Booker was the first to make this connection for me. When hospital birth first began in the US, and for quite some time after, black women were excluded because of racism and classism. Those barriers to receiving care in the hospital created a similar race and class stigma to that I described from Latin America–meaning that women of color might also see midwifery or home birth as the thing you do when you have no other option. Hospitals are the place that people with wealth and privilege go to give birth. Why would one then choose to opt out?

When we talk about midwifery care (and doula care for that matter) needing to be accessible to communities of color–we’re not just talking about Medicaid reimbursement or even language access. It’s a much more complicated sociopolitical history that must be understood. We have to remember and learn how racism has impacted the way we give birth, the options we have, and understand the ways in which that history affects our choices today.

I often feel like discussions of the need to “educate” certain populations are condescending. It implies that we hold knowledge that the other group does not–that we know better than they do what is best for them. Really I think this kind of accessibility will be gained by listening, rather than teaching or educating. By asking the people we seek to reach what keeps them from working with us, what shapes their decisions, and then adjusting our practice accordingly.

In reality, and this is what these articles get at, what will really change the number of people of color using midwifery–it will be midwives of color. Often those from the community themselves are the best advocates and have the cultural competency necessary to serve the community effectively.

Update: Native communities and their history was very absent from this post. In that vein I’m adding a link to this guest post, Why doulas are important in Native American Communities, from Raeanne Madison, which provides some context.

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12 Responses to How can midwifery truly be made accessible to communities of color?

  1. Jill says:

    Thank you for this work and the links. Reducing perinatal disparities is so often untaught and unmentioned in doula trainings. To me, ‘full spectrum’ doula care and education MUST include the examination and dialogue about racial disparities.

  2. Laura Jimenez says:

    Great reflections on a question I have often turned over in my mind…

  3. damidwif says:

    “we’re not just talking about Medicaid reimbursement or even language access.”

    if that is the case, the answer is simple: market midwifery to Black folk. since Blacks consume more tv than than everyone, utilize that form of media. pass out flyers and walk around in the community like Shafia Monroe teaches. talk to black people about the benefits of midwifery, how to choose a practitioner, and then let them make conscious, informed decisions.

    white people gatekeep stuff, midwifery is VERY much included. everything is a secret until white people figure out they can make more money if they have more customers. most midwives are white. in urban areas where i have been a student, there is no shortage of pregnant women of color who use midwives. however, they aren’t choosing it. it was given to them by the benevolent white midwives and the medical system in which they operate to benefit the poor colored folk who are milking their tax dollars with repeat unplanned pregnancies.

    move white women out of the way and bring in black students and midwives who have a vested interest in working in, working for, working with the communities. these women patients are our friends, sisters, aunts, cousins, nieces, granddaughters and sometimes, mothers and grandmothers!

    you know what they do in teaching? in low income areas, housing prices are “subsidized” so that teachers can live in the hood while they work in the hood.

  4. Anon says:

    As far as immigrant attitudes toward midwifery I wonder if the “proof” of citizenship that comes from the hospital is a factor as well. I applied for a passport to travel outside the US and was denied, then found out from their website that the US Passport agency was being sued for denying passports to people born in Texas with midwives (because they suspected it to be a cover for illegal immigration I assume). I don’t know what came of that lawsuit but I’m out $120 and stuck in the US, and unfortunately I can see why immigrants– or anyone else– might want the “legitimacy” of hospital birth. That’s pretty scary.

    @damidwif – As far as white attitudes toward midwives I’m sure you have much more experience than I do. But I was surprised to read that whites guard midwifery because I’ve never met another white person who wasn’t born at a hospital or who met with the idea of home birth with anything other than disbelief and concern. My mother is white and she described her experience of choosing a midwife in the early 80′s as constantly swimming upstream against disapproval and a machine-like medical system. The midwife was a black woman, one of very few midwives working in the area at the time. And that’s really all the experience I have, so I’m just saying I was shocked to learn attitudes have changed so much. I hope attitudes continue to change as you propose because home birth was such a profoundly more positive experience for my mom than hospital birth and more women deserve to have that choice.

    This is obviously a very newbie comment on the well-covered ground of this blog; thank you so much for writing about these issues.

  5. Matt Graber says:

    Reminds me of Ina May Gaskin, and the “Gaskin Maneuver”. She was awarded the Right Livelihood Award in 2011 for her work in promoting the “Gaskin Maneuver” in mid-wifery, as a means of delivering a baby head-first. Knowing the maneuver has allowed midwives to save lives, because it’s a technique that has largely not been taught with medical medicine. Instead, women were told just to get C-sections, and midwives weren’t even taught how to deliver a baby naturally head-first.

    What’s this have to do with POC? Well Ina May Gaskin learned the technique while working in Guatemala from the indigenous people there.

    • sadibird246 says:

      Not really sure where you’re going with this… the Gaskin Maneuver has to do with resolving shoulder dystocia specifically. It’s not really about delivering head-first (seeing as most babies are born that way).

  6. Kelly says:

    sadibird i think i see where the post is meaning to go, tho all the head-first stuff makes it unclear. ina may gaskin got a lot of recognition and an award and an obstetrical maneuver named for her (the only maneuver ever to be named after a woman practitioner!) yet she didn’t originate it. She learned it from indigenous midwives- women of color- and brought it back to her practice in the U.S. (mostly with white women and other white midwives). This “flipping” maneuver was something developed in midwife communities of color in latin america yet it’s named (here in the u.s., in popular consciousness, and in ob practice) after a white person. it’s a roundabout example of the “gatekeeping” mentioned in the earlier post, and i agree.

  7. Cortney says:

    What would you suggest to a white midwifery student who would like to see more black midwives (and people of color serving their own communities) because I have had this same thing run through my mind. How does a white woman promote midwifery to communities or encourage young people about midwifery as a career/life-choice when they may not identify with me as much as they would with someone like Shafia Monroe. I guess I am wondering how to support this needed change from my own place in this world. I want to be clear that I am not suggesting women need only be cared for by practitioners of the same race, but more on serving communities of color on a wider scale if that makes sense…

    • Cortney – my suggestion is to be an ally to the midwives of color out there. Help support scholarships to conferences, help students who are people of color attain apprenticeships, educate other white students about power, privilege, and racism in midwifery. One of the most amazing ally actions I’ve received from a white midwife was her offering to assist me for free knowing I was charging a sliding scale and trying to support my community. Paul Kivel has a great list online of being a white ally and it can easily apply to the midwifery community.

  8. I just wanted to thank you for your thoughtful comments on this subject, which have made me think more deeply about this issue. We talk a lot on my course about social exclusion, and it’s obvious that there are no easy answers. I particularly like your point about listening rather than ‘educating’.

  9. Marcela says:

    Great post, thank you for opening my mind a bit more…

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