Midwifery presents important avenue for fighting health disparities

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Hill with her granddaughter. (Courtesy of Nandi Andrea Hill)

When Nandi Andrea Hill got pregnant at 21, she knew she wanted to have a home birth but couldn’t find a midwife, so she turned to her mother who coached her to have a natural birth without medical interventions. They planned to go to the hospital for the delivery itself, but the baby came faster than they expected. 

“I ended up birthing her at home unplanned with paramedics that came rushing in my room, eight men. They didn’t catch her, she flew out and she did wonderful. They took me to the hospital, but literally when I was putting her up on my chest—I was in culinary arts—I said I need to be a midwife. My community needs a midwife,” Hill said.

Hill is the only Black, licensed midwife working in New Mexico. Throughout Hill’s childhood in 1970s and ‘80s Illinois, her mother attended underground home births with what’s known as a lay midwife—until the midwife, who had eight children of her own, was arrested. 

In an open letter signed by Hill and several other individuals and organizations involved in maternity care, community-based midwifery is presented as one solution to staggeringly disproportionate rates of maternal mortality among Black and Native women, who are two to three times more likely to die from pregnancy-related causes than white women, according to a Centers for Disease Control report

Chart from the Centers for Disease Control and Prevention.

The letter was written in response to an investigation by New Mexico In Depth and ProPublica that found Lovelace Women’s Hospital singled out pregnant Native women for COVID-19 testing and, in some cases, separated them from their newborn babies. Ethicists and clinicians said the practice amounted to racial profiling. After a federal investigation found the hospital violated patients’ rights, Lovelace reported that it had halted the practice, although it did not admit to any wrongdoing. 

The Lovelace racial profiling incidents weren’t outliers, the authors of the letter wrote, but instead pressure on the healthcare system from the COVID-19 pandemic that had exposed the “fault lines” of a racist system not isolated to just one practitioner, department or facility.

In 2018, 658 women in the United States died from pregnancy-related causes—an average rate of 17.4 deaths per 100,000 births. Between 2011 and 2016, the maternal death rate among Black women was 42.4 deaths per 100,000 births, and for Native Americans it was 30.4 deaths. These rates are 3-4 times the rates of other groups. 

The CDC reported a number of factors that contribute to these disparities, including differences in access to care, quality of care and prevalence of chronic diseases. 

Data from state and local Maternal Mortality Review Committees reportedly suggest that the majority of maternal deaths—at least 60%—could have been prevented by addressing those underlying factors. 

To address racial disparities in care, the CDC report recommends hospitals and other health care systems identify and address unconscious stereotyping and attitudes, called “implicit bias,” among healthcare providers to improve interactions, communication and outcomes with patients.  Facilities should also implement standardized protocols, especially those serving disproportionately affected communities, the agency said.

Larrea de Arellano listens to baby’s heartbeat with fetascope. (Courtesy of Breath of My Heart Birthplace)

But local birth workers like Hill and Monica Larrea de Arellano at Española-based Breath of My Heart Birthplace, and other advocates, see community-based midwifery as an alternative to institutional, obstetrical care models that result in racist outcomes like uneven maternal mortality rates. 

Hill said that midwives take a different approach to maternity care than normally experienced with obstetricians. One of the biggest differences is the amount of time they spend with clients both before and after delivery. 

In the weeks following delivery, Hill does multiple check-ups where she notes, for example, if the baby is having any trouble breastfeeding and if there are potential medical threats, like hemorrhaging.  She said she also checks in about their mental health and is available to clients at all times of the day via text or call—practices not found in the obstetrical care model.  

“When we spend more time with them, then we’re able to tailor their care to their needs. We’re also spending a lot more time with them post-child birth, and that’s when we (the United States) are losing a lot of people with pregnancy-related issues,” Hill said. 

Midwifery emphasizes natural birth for women with low-risk pregnancies, unlike the obstetrical care model, within which interventions like caesarian sections or induced labor are fairly commonplace. 

A 2013 study published in the Journal of Perinatal Education reported that while medical interventions used appropriately can be life-saving, routine use can change childbirth from a normal process into a medical or surgical procedure, and possibly lead to additional problems that require even more interventions, that come with their own inherent risks.

The perspectives midwives have about birth compared to obstetricians result in distinctive approaches to delivery, Hill said. 

“I’ve spent hours with people in labor, literally three to four days with people,” she said. “You learn a lot about labor when you do that. So there’s just this different approach and a lot of obstetricians are trained to do surgery, we’re not. We’re trained to look at birth as normal until it presents as not.” 

Midwifery comeback

Midwifery has a long history in New Mexico that has endured despite national efforts to discredit and criminalize the practice dating back to the nineteenth and early twentieth centuries.

A ProPublica article details how midwifery was framed as unscientific and dangerous, and its practitioners—many of whom were Black, Indigenous, immigrant and poor women—as unintelligent and incapable. In 1915, Joseph DeLee, a prominent OB-GYN, called midwives “relics of barbarism” and a North Carolina doctor said Black midwives had “fingers full of dirt” and “brains full of arrogance and superstition.”

DeLee argued for a number of medical interventions, including sedatives and or surgical cuts, in delivery designed to save women from the “evils” that are “natural to labor.” The interventions he recommended became routine. 

Today, midwifery is highly regulated and varies in legality by state. Certified nurse-midwives, who have training in both nursing and midwifery, are less regulated than licensed, direct-entry midwives, who are trained in out-of-hospital settings, and traditional midwives, who are not recognized by most states. 

Within the past few years alone, there are dozens of cases of midwives being arrested. Last year, a woman in New York who had helped deliver hundreds of babies was charged with four felonies for practicing midwifery. The Mennonite women whose babies she had delivered showed up in court to defend her. 

Hill said that one of the results of ongoing criminalization and regulation is that there are much fewer midwives practicing in the United States than there were at the start of the twentieth century. State-by-state restrictions are part of the problem. 

In North Carolina, for example, certified nurse-midwives must have permission from doctors to practice, a requirement that renders them unable to legally work in the 31 counties in the state that don’t have obstetrical care providers, ProPublica reported. 

New Mexico, though, is one of the more welcoming states for midwives, Hill said, which is why she moved here from Illinois 20  years ago. Licensed birth centers—like Breath of My Heart Birthplace—are allowed to operate autonomously and are eligible to seek Medicaid reimbursement for facility fees, an advantage that hospitals already have. 

One researcher found the number of midwives in New Mexico plummeted when the state began regulating and licensing the practice, from about 845 in 1940 to under 100 by 1965. Since then, there’s been a resurgence. Today, there are around 300 licensed midwives practicing in the state, according to the New Mexico Midwives Association.

In 1900, almost all births in the United States happened in out-of-hospital settings. By 1940, that rate had fallen to 44% and then to 1% by 1969 where it has remained with only slight variances.  According to the NM Department of Health, certified nurse midwives in 2017 delivered about 25% of all births that occurred in hospital settings. But, just 518 of the more than 23,000 births that year happened outside of a hospital, either at home or a birth center.

The big accessibility issue Hill sees for people looking to practice midwifery is that schooling is expensive, making midwifery difficult to pursue for marginalized groups who have historically practiced it.

Today, Black licensed midwives represent a small fraction of the midwifery workforce, with Hill estimating that there are no more than 100 working in the country. “That’s just—I want to cry when I hear that, it’s horrible,” Hill said. “It’s a problem of not having access to midwives that look like you.” 

Jessica Frechette-Gutfreund, a gender non-conforming midwife and the executive director of Breath of My Heart Birthplace, shares Hill’s sentiment. 

Jessica Frechette-Gutfreund holds their first child at the Birth of My Heart grand opening gala last year. (Courtesy of Breath of My Heart Birthplace)

“Today it’s a majority white (midwife) workforce practicing in a state (New Mexico) that is majority people of color. Communities used to have their own health care providers who were representatives of their community,” Frechette-Gutfreund said. “Now, communities don’t have their own providers. It’s a really small portion of communities that actually have a midwife that represents them culturally and geographically.” 

Hill suggested state and federal funding for midwifery education programs as one solution. 

In 2019, the U.S. House of Representatives introduced the Midwives for Maximizing Optimal Maternity Services Act, which the American College of Nurse-Midwives said “takes deliberate steps to address the health disparities that disproportionately impact black mothers and other people of color by prioritizing midwifery programs that demonstrate a focus on strengthening and increasing racial and ethnic representation that will help to create a more diverse midwifery workforce.”  

The legislation, cosponsored by Rep. Debra Haaland, is the first time federal policymakers have tried to invest in midwifery education programs, the American College of Nurse-Midwives  said in a press release. It was referred to the Subcommittee on Health in July of last year. 

Last month, nonprofit organization Bold Futures and partners including Larrea de Arellano, presented perinatal emergency recommendations to the New Mexico Legislative Health and Human Services Committee. 

Among the recommendations is the need for health care providers to create an emergency plan to prevent another incident like Lovelace separating Native mothers and their newborns. Another recommendation for health care providers is to inform pregnant people of their options, including out-of-hospital births, which Medicaid covers. 

The authors of the letter say Black, Native and other birth workers and advocates of color should be centered in leadership and decision-making processes related to maternal care.

“Imagine asking people that you’re caring for what they think and how they would like to be treated,” Larrea de Arellano said. “I mean, we wanted to, as an organization, work with all of these other people who are invested in birth work and reproductive justice, and it’s like, who knows who the heck is sitting up in an office making these swooping decisions. It’s like nobody else is involved.”

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