This is part three of a three part series and excerpt from the new book, Battling Over Birth: Black Women and the Maternal Health Care Crisis.
Part One: Prenatal Care Barriers
Part Three: Midwifery Model of Care
“Battling over Birth is a critical and timely resource for understanding black women’s birthing experiences in the United States, a country where black women’s lives—and the lives they create—are at much greater risk of death and injury than those of non-black women … By distilling the common and diverse threads from over 100 black women, the BWBJ researchers have woven a multi-faceted tapestry that reflects what black women view as important and central to optimal birth experiences. Their recommendations for improving care and outcomes are grounded in black women’s authoritative knowledge. … This wonderful, important, necessary research by and for black women points in the direction that black women think we should go to ensure they have safe, healthy, and satisfying birth experiences and outcomes. We need to listen and act.”
—Christine Morton, PhD, author, Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America
Battling Over Birth: Black Women And The Maternal Health Care Crisis
Midwifery Model of Care
In a context where ob-gyns provide both routine care for women experiencing normal, healthy pregnancies as well as specialist care for those experiencing complicated pregnancies, it is unsurprising that many of the women in the study reported that their prenatal visits with ob-gyns were hurried, pressuring and impersonal. In contrast to the U.S. maternal healthcare system, which is dominated by ob-gyns, many countries including Australia, the UK, Sweden and Norway rely on midwives to provide care for the majority of pregnancies. Ob-gyns are thus able to focus their energies on providing individualized care for the minority of cases in which pregnancy complications arise.
There is a long history of African American midwifery, dating back to the West African captives who brought traditional birthing knowledge to the Americas.23 These women became known as “granny midwives,” and they delivered the majority of babies in the South during slavery and post-emancipation. From the 1920s, white male physicians and politicians launched a campaign to move birth from the home into the hospital and to replace midwives with obstetricians. Granny midwives were the victims of a racist/sexist smear campaign that alleged that they were ignorant, unhygienic, superstitious and backwards.24 At first, only white middle-class women were wooed into the hospitals, but after the advent of Medicare, and the desegregation of hospitals in the 1950s, midwife-assisted home births were gradually eliminated in favor of medicalized birth for all women. Today, small numbers of black midwives walk in the footsteps of the granny midwives, offering home births. In addition, predominantly white CNMs staff hospital prenatal clinics and labor and delivery wards.25 However, many black people in the U.S. today believe that modern, safe birth is synonymous with physician-attended hospital birth and see midwifery either as the privilege of white women, or as a relic of an era when black people had no choice but to birth at home and were denied access to segregated hospitals even in cases of life-threatening pregnancy complications. This complex history shows up today in black women’s access to and attitudes toward midwifery care.
Our participants received prenatal care in a range of settings. These included clinic-based care in an ob-gyn or family practice, hospital-based care with an ob-gyn, ob-gyn/midwife mixed hospital clinics, clinic visits with a midwife, group prenatal care at a hospital and home visits with a midwife in anticipation of giving birth in a birthing center or at home. Twenty-three percent of our participants received their prenatal care exclusively with a midwife, or with a midwife-doula team. 15% received a combination of physician and midwifery care. In California, medical researchers estimate that 9-12 percent of pregnant individuals see a CNM.26 Nationwide, 87% see an ob-gyn. However, the proportion of pregnant people receiving care from a midwife, nurse practitioner or physician assistant has grown 48 percent in the past decade27
Characteristics of Midwifery Prenatal Care
A common theme among the participants’ stories was the sharp contrast between prenatal care provided by an ob-gyn and that provided by a midwife.28 Martha experienced midwifery care with a team of midwives from a birthing center after two earlier pregnancies during which she had received the standard short prenatal appointments with an ob-gyn. She compared the short, impersonal ob-gyn visits with the holistic, relational and intimate care she received from
The midwives were amazing. They asked all kinds of questions. Having had appointments with ob-gyns for most of my life that were 10, 5 or 10 minutes. When they asked me, “What do you envision for your birth, and what do you want to eat, and how can we help you and what things about your house do you want changed and who can help you?” It was like, “Oh you’re a friend.” Which was amazing. — Martha, home birth, vaginal birth
By referring to her midwife as a friend, Martha demonstrates the trust and rapport between them, characteristics that lead a pregnant individual to persist with prenatal care and follow the advice she receives from a medical professional. Samirah, who experienced parallel care with both an ob-gyn and a midwife, also noted the relational and intimate nature of her midwife visits. In addition, she revealed the lack of trust created in a hierarchical and inflexible approach to prenatal care. Rather than caring for her as a whole person, she perceived her ob-gyn care as geared toward preparing her for a highly medicalized birth:
My appointments were always so different, I would go to the hospital and it was very rigid, and you know, charting and preparing me for a C-section, you know it was always like WAH! Run out as fast as I could. And my midwife’s appointments were like on the couch and comfortable and you know, like talking about my day, always so different. — Samirah, 37, home birth, vaginal birth
Samirah also appreciated the lack of pressure that she experienced with a midwife. Key to her satisfaction with her prenatal care was the midwife’s commitment to empowering her and her partner to make healthy, informed decisions for themselves. Dalia contrasted this with her ob-gyn who she felt treated her as a disobedient child whenever she disagreed with a proposed course of action:
We found a good midwife. I was not married to having the baby at home. I love that idea but if something goes wrong and we need to go to the hospital my concern is that I have a care provider who has a relationship and has some perspective on what I’m capable of to be my advocate in there. It was fantastic, it was totally different [with the midwife]. I had my appointments at home, I had my baby with me and had my husband there and spent an hour each time talking about whatever. Having things presented to us and choices. And not to feel like I was the rebel every time there was a recommendation, you should do this; your baby’s small at 37 weeks so now you should go have an ultrasound every day, a stress test every day. It was like I was disobeying her. So it was totally different having a midwife. Very relaxed. — Dalia, 40, home birth, vaginal birth
Many of the participants who were able to access midwifery care observed a difference in the philosophy of pregnancy care between ob-gyns and midwives. In their opinion, ob-gyns treated pregnancy like a medical problem or crisis, and tended to utilize numerous and unnecessary interventions that were not tailored to the specific health needs and cultural preferences of the pregnant individual. Participants believed that ob-gyns used fear to ensure compliance with medical advice. In contrast, midwives were more open to exploring alternative approaches to ensure that the pregnant person achieved and maintained optimal health. They used relationship building, trust and listening to build consensus rather than fear and coercion:
And I, that’s kind of the feeling I got, that her advice was based solely on fear. And that’s not usually how I make my decisions. My intuition kind of rose up and I was like, “this is a person who is going to treat my birth like a crisis” And I’m not ready to be in an emergency situation with my birth. I don’t want to feel that. So I walked out of there and I started Yelping “midwife.” — Brianna, 38, home birth, vaginal birth
I was going to [HMO name]; it was a very impersonal experience, that’s what turned me off from the hospital. I knew a hospital was only for an emergency… They wanted to do the diabetes screening and I didn’t feel it was necessary because of the way I took care of myself. I never did it. Every time I went she was like, you have to take it, this is really important. They have all this fear attached to it. They’re just pushing it on you and I’m like no I’m not doing it. And they would call and leave these messages like. We noticed that you didn’t do the test. So then they asked me, are you on prenatals. And I told them I’m not doing no vitamin [pill], I’m taking in this, and all that, I’m telling them about these herbs and vegetables and they asked where does it come from, they don’t know anything. So I called [black midwife’s name] and it was such as relief to have a midwife come to you in your environment and make it so comfortable for you so that you don’t even have to think too much, everything just flows. — Aliyah, 21, home birth, vaginal birth
Rather than focusing narrowly on the pregnant individual’s physical health condition, midwifery care is holistic, and recognizes that a person’s mental, emotional and social wellbeing are affected by and can impact their pregnancy.29 Our participants noted that their midwife helped them to work through difficult emotional or relationship issues that were affecting their emotional preparedness for birth. Amara switched from an ob-gyn practice to a midwife when she was eight months pregnant because she learned that her ob-gyn could quite likely not be present at her birth, and she did not believe in any case that her ob-gyn supported her vision of a natural birth. The emotional care that she received from her midwife was critically important in helping her to release childhood trauma that was triggered when she entered the hospital for childbirth classes:
My last three weeks of prenatal care was heavenly. I had no idea. I mean, the level of beautiful care I got from my midwife, which I should have had my whole pregnancy. Just going, like you said, to a beautiful space, which felt like a women’s center. She’d be like, oh take this stick and pee in the bathroom, honey. Look on the little chart and tell me what it says. It was all like, self-help, do it yourself. We would chat and I said it was a cross between going to visit my grandmother, a therapist, and maybe a nurse. She would talk to me and she was the first person who—I had gone to a birthing class at the hospital and I had had an emotional meltdown. I had been really upset afterwards and I didn’t know what it was about. I was talking to her three weeks before I was due, it became clear to me that I was given up. I was birthed but then my mother left me in the hospital.
What was coming up for me was all that body memory of babies in hospitals and being abandoned and all this kind of thing. I would have been an emotional wreck if I was trying to give birth in a hospital without realizing that was going on for me. So my midwife acted as my therapist and helped me to talk it through. She was this very kind of petite woman but she was very hardcore and she just said, “You’ve got to leave that behind. That’s not your birth story anymore. You’re having a new birth story.” It was just putting it on the table and sharing that was really powerful. By the time I got to my birth, which was a week later from the due date. It was four weeks later from moving to this midwife. I felt prepared emotionally. — Amara, 41, hospital, vaginal birth
Hailey found her midwife’s assistance in navigating a challenging relationship with the father of her unborn child essential to her emotional wellbeing during her last trimester. She also appreciated how the midwife worked to support and empower the partner or in this case ex-partner as well as the pregnant person.
I ended up finding my midwife when I was 30 weeks pregnant. She was amazing… She had a great team. They really took care of us from the prenatal part and she really helped with relationship issues, because we were broken up, “How do we put this together? Do we even want to proceed as a family? Or should we just be friends? What is his role going to be as a father?” But she made sure to include my husband in the entire process, and he felt empowered as well as I. — Hailey, 31, home birth, vaginal birth