[continued] in the U.S.
Neelu Shruti • 2021 Issue
From The Editors:
Until the early-1900s, births in the United States were largely attended by midwives. However, the onset of a new medical establishment transformed the care of otherwise healthy physiological birthing people into a medically-managed event by increasing unnecessary interventions, eliminating community midwives and moving birth out of community settings and into hospitals. Today, the U.S. is the only developed country where maternal mortality is increasing and racial disparities in maternal mortality continue to persist. Through a case-study analysis of New York City during the COVID-19 pandemic in BIRTH JUSTICE DENIED, Shruti argues for the urgent need to eliminate barriers to access for community midwives and community birth centers to move toward achieving birth justice for the birthing people of New York.
When I tell people that I am in midwifery school, I’m often asked, “Like a doula?” For those who need clarification, a midwife is a healthcare provider who is skilled in the full-spectrum medical care of anyone who needs gynecological care, including cis and trans women and other transgender and gender-nonconforming people who need it. In short, midwives are similar to obstetricians-gynecologists, with the exception of leading a surgery, whereas doulas are non-medical emotional-support workers who shepherd people through the process of pregnancy, birth, postpartum, miscarriage, abortion and loss.
It bears asking, from a historical perspective: Why does this distinction, and the validity of the midwifery profession, continuously need to be re-explained?
The historical racist and sexist marginalization of Black, Indigenous and Immigrant midwives
Before the racist emergence of gynecology in the work of J. Marion Sims, who infamously performed surgical experiments on enslaved, unmedicated Black women in order to develop modern gynecological procedures, the experience of birth in most places around the world was one led and supported by traditional midwives in their communities. Indigenous, African, and Eurasian midwives – equipped with knowledge of the human body and of herbal remedies alike – were the healers who supported people through their reproductive journeys.
The entrenchment of racism in US birth culture is a long and complex story. From the earliest days of the Transatlantic Slave Trade, Black people’s reproduction and bodies have been central to racial capitalism. Not only has their physical labor been exploited, but their reproductive labor has been appropriated – to (re)create a captive workforce under slavery, as wet nurses and midwives, and even as testing subjects for Marion Sims, in birth control experiments, or in the iconic case of Henrietta Lacks.
In the early 20th century, births in the US were largely attended at home by immigrant, indigenous, and grandmother midwives. These midwives generally had extensive training in their home countries or indigenous communities, whether in the form of apprenticeship or formal instruction. But as medical schools pumped out “poorly trained or untrained medical practitioners”– mostly male and far less knowledgeable than midwives – numbers of these ‘doctors’ far outstripped medical positions available. The American Medical Association – in a concerted campaign based on the findings of the Carnegie Foundation-funded Flexner Report - moved birth out of community settings and into hospitals. In doing so they transformed birth, a physiological event, into a medically managed condition, while in the process, convincing people that birth required ‘medical interventions and management’. The new medical establishment, made up mostly of white, male physicians and white nurses, eliminated community midwives through legislation such as the 1921 Sheppard-Towner Act which painted them as dirty, ignorant, and uneducated, and even banned their commonly used midwifery tools in a racist ad campaign under the guise of maternal and infant protection.
Subsequently, the practice of midwifery was outlawed in many states; as in the case of the brutal witch-hunts of the European middle ages, and settler-colonial North America, processes that were ostensibly about rooting out harmful practices were in fact mobilized to destroy bases of female power.
An intensive study showed a 41% increase in maternal mortality due to obstetric interference and birth injury between 1915 and 1929. In comparison, home births attended by midwives during this time had the lowest maternal mortality rate of any setting, while two-thirds of maternal hospital deaths were preventable.
In 1900, the United States had 100,000 midwives (about half of whom were black), and midwives attended approximately half of all births. Today, it is estimated that there are just under 15,000 midwives, (fewer than 1,000 of whom are Black) who attend 8% of births in the United States. While some may allege that midwives were guilty of uniquely unsanitary and unscientific practices, the reality – as current circumstances make clear – is that midwifery can be practiced in line with modern conceptions of hygiene just as well as gynecology can be.
A capitalist campaign to move birth out of the community and into hospitals
From the 1920s onward, the ruse was that inexperienced obstetricians – rather than consult with midwives – could recruit birthing people to hospitals which would serve as training sites for physicians. According to this logic, through ‘professionalization’, obstetricians could become scientifically-empowered modern physicians., Conversely, midwives were not allowed entry into medical schools and allegedly not capable of adjusting to changes brought on by germ theory and other advances in biomedicine and public health.
Underlying this deception was the fact that moving birth into hospitals resulted in inappropriate and excessive surgical and obstetric interventions, but, as a financial boon for the US medical industry, created strong financial incentives for the medical establishment to oppose any efforts to reimagine safe, modern, out-of-hospital birth. Birth is a physiological process, not (except in specific cases) a medical event to be managed, and evidence shows that 9 out of 10 of birthing people would safely qualify for out-of-hospital birth. People giving birth with midwives in community settings have better outcomes, on average – including lower C-section rates, and lower maternal mortality – than those who give birth with medical providers in hospitals, and U.S. states with more support for midwives have objectively better birth outcomes. Despite these better outcomes, 98% of births take place in hospitals in the US, a far higher percentage than in other rich countries. Meanwhile, in Canada and Europe, processes of professionalization allowed for the continued existence of midwifery as an independent profession integrated into the medical system – a fact reflected in their comparably favorable maternal mortality statistics today.
Why, then, year after year, is so little progress made on birth policy and birth practice in the US?
In short, the barriers are not technical, medical, or scientific, but political and inherently racialized. A key barrier to the training and licensure of more midwives is the stranglehold (white) nursing and midwifery organizations have on US maternity care. Physicians and medical professional bodies continue to protect their own interests by maintaining arbitrary and – from a health perspective – unnecessary educational barriers (such as the requirement to obtain a nursing degree or a graduate degree to practice midwifery), and a tight hold on accreditation at a state-by-state level. Forces that have blocked the advancement of midwifery and out-of-hospital birth in the US include the American Medical Association (AMA), the American College of Obstetricians and Gynecologists (ACOG), the hospital industry, insurance companies (both private insurance providers and malpractice insurers), and professional organizations like the American Nurses Association (ANA). Sadly, even the largely white-led American College of Nurse Midwives (ACNM) and the Midwives Alliance of North America (MANA) – the key bodies that have structured the reemergence of midwifery in the US since the latter half of the twentieth century – have delayed progress on US birth policy by diverging with each other on midwifery education regulations, among other issues.
Without options: lack of community midwives and birth centers, exacerbates the birthing crisis during the COVID-19 pandemic in NY
Much attention has been paid to the racial disparities in maternal mortality in the US, and, although the data are often incomplete and unreliable, there is evidence that maternal health disparities between Black and white women have changed very little since the end of slavery, (although, of course, the overall standard of health, including of maternal health, has improved dramatically in that time, owing largely to the transformative public health breakthroughs). There is no doubt that structural racism is the root cause for these disparities, and it is clear that – especially under the pressures of austerity, consolidation, and profit-maximization that have been central to neoliberalism – the medical-industrial complex is failing birthing people in the US.
Zooming in on New York City, where racial disparities in maternal mortality are among the most stark in the country, the failure of medical institutions to support birthing people came into stark view in the height of the first wave of the COVID-19 pandemic. In March and April, as NYC’s hospitals were overwhelmed by critically-ill COVID patients, people giving birth were offered no out of hospital birth alternatives.The City’s 20 home birth midwifery practices were flooded with calls, and the City’s two free-standing birth centers (both led by physicians, not midwives) were suddenly at capacity with interminable waiting lists.
While other states and other countries built birthing centers in hotels and took other steps to create capacity for COVID-negative pregnant people to deliver in out-of-hospital birth settings, pregnant people in NYC had few options. Some fled the city or changed care providers if they could afford to, gave birth at home, unattended, rather than risk going to the hospital, or suffered through the mistreatment and, in some cases, the violation of their rights in hospital, which, tragically, led to maternal and infant deaths. The onslaught of the COVID-19 pandemic in New York City points to long-standing structural failures with respect to, among other things, maternal healthcare and birth policy. To improve outcomes for birthing people in New York City, the biggest need is for more midwives of color.
Why does a state as diverse as New York lack Midwives? Why does a state like NY not have the capacity for safe out-of-hospital births when 85% of birthing people are considered low risk and would qualify? Why does NY State have among the highest C-section rates in the country (above 35%) when the WHO suggests that only roughly 10% of birthing people require medically-necessary Cesareans?
The urgent need to eliminate barriers for practice and education for Community Midwives in New York
After the Sheppard-Towner Act of the 1920s professionalized nursing and midwifery care, and thus sidelined grandmother, indigenous, and community midwives (disproportionately of color), physicians left the work of serving the maternity care needs of poor populations to nurse-midwives (mostly white). As the number of community midwives of color dwindled, white nurse-midwives, instead of taking their places in communities, practiced primarily in hospitals, where they would discreetly offer options to birthing people while still operating within hospital hierarchies. Nonetheless, at the margins, community midwives (who came to be known as Certified Professional Midwives or CPMs) continued to operate in New York until the passage of the 1992 Midwifery Practice Act, when – in a startling blow – CPMs were left out of legislation meant to further professionalize midwifery. The act ensured that nurse-midwives and those with nursing-equivalent graduate degrees – only 7% of whom are of color in the US – enjoyed the privilege to practice in NYS, while practice by CPMs – 21% of whom are of color – became a felony.
Community midwives (known as Certified Professional Midwives or CPMs) were excluded from practicing in NY State s on the basis that CPMs do not hold a graduate degree or nursing equivalent education,even though their practical training is more rigorous and they are licensed in 35 other states. As a result not only are CPMs barred from practice in NY, they are criminalized, arrested and prosecuted. During the COVID-19 pandemic, restrictions against CPMs in New York were lifted temporarily with an Executive Order when the need for community healthcare workers was dire, but since the order’s expiration CPMs have once again begun to be arrested. If they are suddenly qualified to practice when needed, why was it illegal for them to practice before?
In a sad commentary on the state of birth affairs in NYS, the first Black-owned midwifery school in the US was opened in 2020 by Jennie Joseph, and yet, according to NYS law, graduates of her school would be criminalized if they tried to practice in New York. As a black midwife, Jennie Joseph’s approach in two birth centers that she owns has proven to eradicate disparities in birth outcomes.
The urgent need to eliminate barriers for Birth Centers in New York
Many birth centers have closed in NYS over the last 20 years. Low insurance reimbursements, high malpractice insurance rates, and structural shifts of the healthcare industry characterized by consolidation, cost-cutting, and profit-maximization that have privileged revenue-per-square-foot over quality of care have all played a role in driving these closures. (To explain why midwives are paid far less than OBGYNs for the same services would require another article!) As of 2001, NYC had four free-standing birth centers and multiple within-hospital birth centers or midwifery-led care floors. Now, NYS has just three out of the 345 birth centers in the United States, with just two in NYC.
In 2016, under pressure from birth advocates and activists, NYS finally passed the Birth Center Act, allowing midwives – in theory – to open their own birth centers (which until that point, by law, had been physician-led). However, in practice, as NYC continued to lose even in-hospital birth centers – such as the one at Mt. Sinai West (which was closed to make way for more profitable NICU and private postpartum rooms) – the creation of an actual path to the opening of midwife-led birth centers remained stalled. Only in 2019 did the NYS Department of Health (DOH) finally pass regulations for midwife-led birth centers, so that when the COVID-19 pandemic ripped through NYC in March 2020, all that blocked the legal creation of such birth centers in NYS was the finalization by DOH of a process of licensure.
Only grassroots efforts during the pandemic and appeals to the governor at last led to the completion of the licensure process in the summer of 2020. There are still no midwife led birth centers in NY.
Unfortunately, once the licensure process was finalized (four years after passage of the 2016 Birth Center Act), it became evident that rather than follow nationally-available birth center accreditation guidelines, the DOH had chosen to categorize birth centers in NYS as hospital facilities and thus to subject them to compliance with the burdensome Certificate of Need (CON) process – an expensive and time-consuming process designed to apply to large hospitals, not small, freestanding facilities. Further, the CON process is overseen by the Public Health and Health Planning Council, an entirely executive-appointed body that effectively represents the healthcare industry; there are no midwives or birth advocates on the board and out of 25 members, only one is a woman of color.
Pioneered by NYC, CON laws were designed, ostensibly, to keep prices for patients low, but they now largely serve to protect healthcare monopolies. Studies show that CON laws increase costs and spending; reduce hospital capacity and access and require people to travel greater distances for healthcare. Although these laws are justified in the name of safety, they are associated with poorer outcomes and greater racial disparities in care,,,. Many other US states rely on the Commission for the Accreditation of Birth Centers (or CABC, a well-reputed national body that specializes, as its name suggests, in accrediting birth centers) to credential birth centers. In California, where birth centers are subject to national accreditation standards, not only are there far more birth centers (approximately 56; nearly 10x more per capita than in NYS), but birthing people experience far better outcomes than do those in NYS.
The path forward to achieving birth justice and liberation
Ironically, though, New York City has a strong public health tradition, including with respect to perinatal care. In the 1920s, New York City instituted a program through which midwives visited at home all families expecting a baby to provide free prenatal – and, after birth – postpartum, and baby care. There were also 68 baby clinics across the city (think of these as being like New York’s remarkable public library system) that provided free child and baby care. No surprise, the maternal mortality rate dropped staggeringly. These programs were cut during NYC’s 1970s fiscal crisis. Since then, all but two of NYC’s birth centers have been forced to close due to lack of insurance reimbursements for midwife-attended births, high malpractice insurance, hospital consolidation, healthcare cost-cutting, and an obscene focus on revenue-per-square-foot over quality of care. Maternity care in the United States was in a crisis pre-COVID, and the pandemic has exacerbated this crisis as it has so many other structural failures of US racial capitalism. The medical establishment has largely taken birth out of community settings, creating further reliance on hospital-based maternity care.During disasters and pandemics that overwhelm hospital systems already attenuated by neoliberal cost-cutting and ‘optimization,’ people giving birth in those hospital settings are completely sidelined and face mounting hurdles to receive respectful and safe care.In the last year alone, NYC has had to reckon with the highly-preventable and publicized deaths of Amber Rose Isaac, Sha’Asia Washington, and Cordelia Street.
These are some of the unique ways in which birth policies are formulated – geared to protect entrenched interests; profoundly racialized; oriented, always, towards profit-maximization for often monopolistic industries, and professions that have effectively weaponized regulation; and running counter to logic, science, and evidence-based best practices. Sadly, this results predictably in exploitation, and while birth centers and community midwives are no panacea for the harms wrought by white supremacy and racial capitalism, there is a strong case that common-sense improvements in birth policy and practice can improve outcomes for all birthing people, especially those already structurally most vulnerable to mistreatment. That birth centers also improve the experience of care, improve the health of populations, and reduce per-capita costs of healthcare can be seen as added benefits, and enabling midwives of color to expand birth centers in their own communities should thus be seen as essential.
The U.S. can achieve better outcomes for birthing people. We can expand full scope of practice and access to midwives, particularly midwives of color; lift undue restrictions to open community birth centers; formally integrate midwives into the health system and compensate fairly to make the profession sustainable; remove educational roadblocks to midwifery education; ensure affordable, accessible healthcare, paid family leave and sick leave for all. But as a society we must grapple with structural racism that is the root cause of injustice and recognize that the solutions to politically-generated problems are obvious and not technical, or at the level of policy, but readily at hand with the recognition that the struggle is not impossible but political.
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