“Black Lives Matter!” was the cry of millions of people who took to the streets last spring following the police murder of George Floyd. Among the names chanted were those of Amber Rose Isaac, Sha’Asia Washington, and Cordielle Street, three Black mothers who died during or right after giving birth. Black people in the United States suffer disproportionately when they give birth, due to centuries of structural racism and a medical system that over the past century has labored mightily to turn birth from a natural physiological process into an expensive medical procedure.
The U.S. has the highest healthcare spending per capita and the costliest births in the world, yet maternal mortality persists and is on the rise. In 2018, maternal mortality rates reached 17.4 per 100,000 births, more than twice the rate in the 1990s. Nationally, Black people are more than three times as likely as white counterparts to die of complications from pregnancy or birth. In NYC, that disparity is a staggering 12 times more likely.
In 1900, the United States had 100,000 midwives, and they attended approximately half of all births. Many Black, immigrant, and indigenous midwives had extensive training in their home countries or communities, whether in the form of apprenticeship or formal instruction. Today, it is estimated that there are just under 15,000 midwives in the U.S., fewer than 1,000 of whom are Black, and they attend only eight percent of births.
In a concerted campaign based on the findings of the 1910 Carnegie Foundation-funded Flexner Report, the American Medical Association set out to move birth out of community settings and into hospitals, convincing people that birth required “medical interventions and management.” The new (mostly white) medical establishment of physicians and nurses disenfranchised community midwives through legislation – such as the federal Sheppard-Towner Act of 1921, which painted midwives as dirty, ignorant, and uneducated – and through a racist ad campaign masquerading as maternal and infant protection. The medical profession moved births out of community and into hospital settings, even though a study by the New York Academy of Medicine in 1932 found that home births attended by midwives had the lowest maternal mortality rate of any setting, while two-thirds of maternal hospital deaths were preventable.
Evidence shows that 85% of pregnant people would safely qualify for out-of-hospital birth. People giving birth with midwives in community settings such as birth centers and home births have better outcomes, on average, including lower rates of cesarean sections and mortality. Nonetheless, 98% of births in the U.S. take place in hospitals, a far higher percentage than in other rich countries.
As the shift from largely at-home to in-hospital birth took place, the myth persisted that midwives rooted in communities and ancient traditions were not capable of adjusting to the 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 under the purview of physicians was a financial boon for the U.S. medical industry.
New York State’s policy dysfunction
The Sheppard-Towner Act led to the decimation of Black, immigrant, and indigenous community midwifery and in its place created a new professional class of white nurse-midwives who largely served the maternity care needs of poor populations, primarily in hospitals. Nonetheless, in New York State (NYS), community midwives – who are trained in birth-center and home birth, and now formally known as Certified Professional Midwives (CPMs) – continued to work alongside their nurse-midwife counterparts until the passage of the 1992 Midwifery Practice Act, which was meant to professionalize midwifery standards, but excluded CPMs entirely. The act ensured that nurse-midwives and those with nursing-equivalent graduate degrees — only 7% of whom are of color in the U.S. — enjoyed the privilege to practice in the state, while practice by CPMs — 21% of whom are of color — became a felony. As a result, while CPMs are currently licensed to practice in 37 other states, they are banned from practicing in NYS.
During the pandemic, CPMs licensed in other states were allowed to practice in NYS, but the state has continued to withhold permanent recognition and licensure to its own CPMs. It is imperative the midwifery workforce be expanded, especially in populations where midwives have been prevented from carrying on their ancestral profession. Fortunately, a bill should soon be introduced in the State Assembly to license CPMs; however, it will take a wave of public pressure to ensure the bill makes it through the gauntlet of Albany legislative procedures to be enacted.
As for out-of-hospital birth options, many birth centers in the state have closed over the last 20 years. Now, only three of the 400 birth centers in the U.S. are in NYS, with two of them in NYC. In contrast California has 56, Texas has 92, and Florida has 32 birth centers. Factors driving these closures include low insurance reimbursements; high malpractice insurance rates; and consolidation, cost-cutting, and profit-maximization in the healthcare industry, where revenue per square foot is more important than quality of care.
In 2016, NYS passed the Birth Center Act, allowing midwives — in theory — to open their own birth centers, which, prior to that point, could only legally be run by physicians. However, it took the Department of Health (DOH) until 2019 to promulgate regulations for midwife-led birth centers, and the DOH had still not finalized the licensing process when the COVID-19 pandemic ripped through NYC in March 2020.
As ambulances carrying COVID patients to overcrowded emergency rooms screamed through abandoned streets, many birthing people were terrified of entering hospitals. The city’s two birth centers and 20 homebirth midwifery practices were inundated with requests, with some receiving as many inquiries in one day as they normally did in a year.
Birth-justice advocates put forward plans to create makeshift birth centers and put pressure on the Governor to direct the DOH to finalize its licensure process. After much outcry, it became evident that rather than follow nationally recognized birth center accreditation guidelines, the DOH had instead chosen to create burdensome regulations – chief among them, the Certificate of Need (CON) process.
Originally intended to keep healthcare costs for patients low, CON laws now essentially serve to maintain hospital monopolies and have been shown to increase costs, reduce access, and increase disparities in care. The expensive and time-consuming process was designed to apply to large hospitals, not small, freestanding facilities and, in NYS, is overseen by the Public Health and Health Planning Council, which is entirely appointed by the Governor, represents large healthcare organizations, and includes no birth advocates and only two women on its board.
Several groups of midwives are ready to open birth centers in the state, including two in NYC, both led by women of color. But for most of them, bureaucratic and financial hurdles, exemplified by the CON process, appear insurmountable.
Owing to grassroots efforts, the NYS Assembly and Senate recently passed a bill to make national accreditation sufficient for licensure of birth centers in NYS, but the work continues to ensure that the Governor signs the bill and DOH regulations eliminate the CON process for birth centers.
In the name of birth justice, New York must offer true choices for birthing people by making midwifery care and birthing centers accessible and affordable to all. Anything less would be justice denied.
Neelu Shruti is a birth justice advocate, midwifery student, and the founder of Love Child, a support space for expecting and new parents located in Manhattan’s West Village.
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