Once upon a time, midwifery in the US was a Black woman’s trade. Enslaved women were in charge of deliveries, and passed the knowledge of childbirth through generations. Yet today, 90% of midwives in the country are white, and fewer than 700 are Black.
This is a result of the evolution of the field of gynecology in the US, which first stripped Black women of their role in childbirth—replacing Black midwives with white doctors—then made midwifery a privilege accessible only to few, typically white upper-middle class women.
Yet even as the field of midwifery continues to grow, women of color, particularly Black women, have a hard time entering the field. This is especially detrimental to Black mothers, who experience a risk of maternal mortality up to four times higher than their white counterparts, and are proven to have better outcomes when treated by midwives of color.
To understand how to address the lack of diversity in the field, a paper published in the latest issue of Health Service Research looked at the barriers faced by aspiring midwives, as well as the reasons they enter the field. They found that for midwives of color: racism was both a hindrance and a motivation.
An individual action against racism in childbirth
The study surveyed nearly 800 aspiring midwives of color, with 76 questions on the reasons they were interested in pursuing a career in the field, and the main obstacles they encountered.
For the overwhelming majority (88%) the main reason was providing racially concordant care (that is, healthcare provided to people of a particular ethnicity by people from the same group) for community members, followed by reducing racial disparities in health (67%), and personal experiences related to midwifery care (55%). In other words, people of color exposed, in first person or indirectly, to the outcomes of being treated by midwives and other birth workers, who don’t belong to their community, become aware of the racist dynamics that permeate the field, and have decided to take matters into their own hands.
“I didn’t have a lot of awareness around racism when I wasn’t pregnant. It wasn’t until my second pregnancy where I was asking for pain management and I was basically ignored,” said a Black woman in her 30s from the south who was interviewed for the survey. “And I absolutely believe that it was because I was in this brown body.”
Other women interviewed reported being denied pain management, and generally being mistreated by hospital staff, including after miscarriages. “I have come across so many women in my community with horror stories about their hospital experiences and yet were too afraid to step outside the box because no one looked like them,” said another Black woman in her 30s, explaining her desire to encourage people in her community to trust midwifery. “I want to bridge the gap for my sisters.”
Others interviewed in the survey expressed similar sentiments with regard to gender representation as well as race and ethnicity. “Not enough practices are inclusive let alone queer centric—I find that I always have to silence being with Black or Queer in order to navigate the birthkeeping world and it’s discouraging,” said a multiracial Latinx person in their 30s from the midwest, who turned this discouragement into a reason to provide midwifery services to queer and trans pregnant people.
The systemic reaction of racism in midwifery
Yet in the face of this individual motivation, racism remains the force that presents the most challenges on the path to becoming a midwife, says Renee Mehra, a researcher at the School of Nursing at the University of California, San Francisco and the lead author of the paper.
In some of these challenges, racism is indirectly involved. For instance, says Mehra, the inability to pay for midwifery education, or being unable to secure childcare or healthcare coverage while in school, don’t just impact women of color, though they disproportionately do, as ethnic minorities are more likely to experience low socioeconomic status.
“No Certified Professional Midwife program is supportive for the person that must work full time to support themselves. I am single, yes, but I pay all my own bills, some of my family’s (mother, niece, grandma) [bills], and prior educational loans. Since this is my second degree or program, I pay out of pocket. I cannot do that and not work,” said a Black woman from the south in her 30s, who is studying to be a midwife.
“The hardest part of the process was finding funding and now it is choosing to stay in a program that has so many structural issues within it,” said an indigenous woman in her 30s from the west. “We already lost 1/4 of our cohort because how our program is structured and not able to support people of Color through this process.”
But there are also issues that are more clearly race-related, including the lack of representation in the field. Aspiring midwives of color, says Mehra, report a lack of professors and mentors who belong to their community, as well as difficulties finding guidance from from white professionals. “I have [...] tried reaching out to white midwives in my area to see if I can study under them, but I get no response,” said a Black woman in her 20s from the south.
While addressing financial barriers is somewhat simpler to solve—more funding, better scholarships, stronger support systems—providing the representation and mentoring many are looking for is complex, because it could take time to form a diverse workforce. “There is a broader desire from aspiring midwives to have a more culturally competent education, and traditional and ancestral practices,” says Mehra.
This sentiment was expressed by a Black Latina woman from the south in her 20s, who said, “[A]s a Black birth worker I am lacking in so much ancestral and cultural info that I would receive working with birthkeepers that look like me.”