A Welcome Note:

We will include many invitations throughout this paper to pause, breath, and reflect on how you’re feeling at this moment. How does your belly feel? What does your heart want to do or say about what you’ve just read? These invitations to feel an emotional response in your body, as you are also processing information in your mind, is recommended by racial justice and somatic abolitionists such as Resmaa Menakem, author of New York Times Best Selling book, My Grandmother’s Hands.

We invite you to take at least one full, deep breath, notice your feet, and perhaps place a hand on your belly, when these prompts arrive, to help you avoid becoming overwhelmed or burning out from sadness, grief, shame or disgust that you may experience while reading about parts of our society that none of us like to embrace. You may have a lot of feelings from what you read here! But this is a part of U.S. culture, and we cannot address something we cannot see and accept.

It’s a marathon, not a sprint. Take your time. Take breaks. Don’t wait too long to come back.

You may need practices to keep your feelings close, rather than pushing them away. Your emotions area form of information and evidence in your own story–write down and reflect on this personal data to inform you of gaps in your understanding, energize you when the work seems hard or impossible, and to motivate you toward the action items that resonate with you most. In the powerful words of Glennon Doyle: “We can do hard things!” We hope that reading this paper is a hard thing, that is also informational, inspiring, and perhaps even transformative for you and your communities.

Podcast Conversation about this Signature Article: 

Listen to a conversation on this article (focused on Birth Equity) with the lead author, Ihotu Ali, and the co-author, Rebecca Dekker.

On May 25, 2020, a cell phone captured video of U.S. police officer Derek Chauvin’s knee pinned on the neck of 46-year-old George Floyd for eight minutes and forty-six seconds. He pleaded for his life, saying “I can’t breathe.” He called out for his mother, and his last words were “Tell my kids I love them.” The story and video of Mr. Floyd’s murder looped continuously on major news networks over the following days, and on June 1st, Rebecca Dekker, the founder of Evidence Based Birth® (EBB) sent an email and posted a video to the EBB community saying:  

“I continue to be horrified that the country I live in still brutalizes and murders people with Black bodies. My heart goes out to all of you who are suffering and grieving and reliving trauma right now.”  

Pause, breathe, and notice your body’s response. 

Rebecca also spoke to racism that impacts birth outcomes, leading to 3-4 times higher death rates for Black birthing people and babies, and three areas of responsibility she chose to take on as a white person living in America: being a follower of Black leadership, talking with her children, and holding other white people accountable.  

She wasn’t sure if she would say the “right thing,” but saying something felt more important to her than saying nothing. Rebecca had also made it a priority to build relationships with Black and Brown birth workers and to ask them what they really thought and felt on issues like this. She might always make mistakes, but she had learned to focus on empathy, care, and protection in her words, as if she were speaking to a close friend or family member.  

Ihotu Jennifer Ali, an EBB Professional Member and Minneapolis-based birth worker, replied to Rebecca’s message and asked for support in highlighting birth workers on the frontlines of the protests as a part of the Minnesota Healing Justice Network, a collective of over 100 community healers, doulas and midwives of color. When Rebecca replied asking what they recommend, Ihotu and other members of the network including: Daniela Montoya-Barthelemy, MPH; Shayla Walker; Rhonda Fellows, CD (DONA), EBB Instructor; and Jennifer Almanza, DNP, APRN, CNM, suggested that Evidence Based Birth® make the research on racism and perinatal health more easily accessible to all. 

EBB started by publishing “Black Tiles” on Instagram –using social media posts on a black background to highlight and summarize research on the impact of racism on perinatal health outcomes, at a time when so many were turning to social media for advocacy and education.  

The Black Tiles were also used to recognize leaders in Black birth and anti-racism advocacy, and to acknowledge that there are solutions supported by the evidence, such as training more Black providers, and making midwives and doulas more accessible to families of color (Greenwood et al., 2020; Vedam et al., 2019; Kozhimannil et al., 2013).  

Ihotu eventually joined the EBB Research Team to support the Black Tiles project, and six months later became the lead drafter and author of this article. The purpose of this EBB Signature Article is to compile all the Black Tiles into a single resource, provide a public summary of over 100 studies focusing on racism and white supremacy in obstetric health care, and to suggest action steps supported by evidence that birth workers can take to bring anti-racism into their daily lives. 

The vision for this Signature Article was born out of collaboration and crisis – it carries forward EBB’s vision of making birth research more accessible, and honors a grassroots request from Black, Brown, and Indigenous birth workers in Minneapolis. As the months went by, this vision evolved from simply presenting the research to offering specific and sustainable action ideas for allies, publishing advocacy scripts for interrupting racism in the moment, and providing support to racial justice and birth justice advocates – across all races and walks of life. 

What we don’t know can hurt us – and hurt others

More than twenty years ago, Brian Smedley, lead editor of the landmark report, Unequal Treatment, said “We are still largely seeing what some would call medical apartheid.” The report reviewed over 100 studies and found consistent evidence of racism embedded in the U.S. health care system.  

Tragically, we continue to see racism leading to the same outcomes two decades later: 

• Racial minority patients receive a lower quality of medical care than white patients, including facing more challenges in getting an appointment, and being offered less time with the doctor and fewer clinically necessary procedures (Wisniewski and Walker, 2020; Penner, Dovidio, Gonzalez et al., 2016). 
• Black women and birthing people are 3-4 times more likely to die from pregnancy-related causes than white people, and 5 times more likely to die from pregnancy-related cardiomyopathy and blood pressure disorders, while over 60% of maternal deaths are considered preventable (MacDorman, Toma, Declerq et al., 2021; Centers for Disease Control and Maternal Mortality Review Boards).  

• Black patients who were born in the United States are 26% more likely to develop preeclampsia than Black immigrants born elsewhere, and the risk of preeclampsia increases for all Black immigrants after 10 years of residence in the U.S. (Boakye, Koapong, Obisesan et al., 2021). 
• Black patients are more likely to experience coercion and forced perinatal procedures compared to white patients (Logan, McLemore, Julian et al., 2022).  

Pause, breathe, and notice your body’s response. 

Data from peer-reviewed studies, the Centers for Disease Control, and Maternal Mortality Review Boards across the United States confirm that Black and Indigenous birthing people die at higher rates than white birthing people (Giscombe and Lobel, 2005). The racial disparity in birth outcomes remains even after considering socioeconomic status and level of education, showing that poverty or lack of education are not the reasons why Black people are dying at higher rates in childbirth. To paraphrase a quote from Dr. Joia Crear-Perry, OB-GYN, policy expert, thought leader and the Founder of the National Black Equity Collaborative: “Race isn’t the risk factor – racism is.” 

How is racism a factor?

First, research shows that the stress of experiencing racism (also called allostatic load) leads to a biological “weathering” effect on the body that can cause accelerated cellular aging and early onset of disease, including elevated blood pressure and heart rate (Geronimus et al., 2006; Carter et al., 2019; Chae et al., 2020; Collins et al., 2004).  

Second, the impact of racism can be felt through both systemic and interpersonal interactions. For example, statistics from the Unequal Treatment report demonstrate that many white providers offer lower quality health care, shorter appointments, and fewer standard procedures to patients of color. In other words, people of color do not always receive the same quality of health care as white people.  

Pause, breathe, and notice your body’s response. 

White health care workers are not a monolith– but they hold a variety of beliefs about race and racism, which can impact how they deliver care. A 2017 study showed that half of white people believe that racism is a hoax that doesn’t truly exist (Douglas et al., 2017). Another study by Hoffman et al. from 2016 found that many white laypeople hold biologically false beliefs about Black people, including that Black couples are more fertile (17%), that Black people’s skin is thicker (58%), their immune systems stronger (14%) and with blood that clots more quickly (39%) than white people.  

Even after medical training, up to 25% of resident doctors continued to endorse some of these false stereotypes and were more likely to rate a Black patient’s pain as lower than a white patient’s pain, and more likely to recommend insufficient pain relief for fictional Black patients in the study.  

Pause, breathe, and notice your body’s response. 

After reviewing this research, and recollecting real-life scenarios we have witnessed, we have created a handout that demonstrates how racism, as a risk factor, can harm Black people who are pregnant, birthing, or postpartum. To view this handout, see Part 3 of this Anti-Racism series [coming soon].  

Research can help white people about “blank spots”

Dr. Camara Jones, former President of the American Public Health Association, compares racism in the United States to a sign hanging in a restaurant window, where one side reads “Open” while the other reads “Closed.” If you are seeing the “Open” side, it can be challenging to understand that people on the other side of the window are receiving a very different message.  

Advocates like comedian Franchesca Ramsey (@chescaleigh) and others have used similar analogies for white privilege like wearing “horse blinders” or missing the blind spot in a car rearview mirror. We all have blank spots because we only have one unique life experience to draw from. Reading research (quantitative data) and listening to other’s stories (qualitative data) can help us learn about others’ life experiences, understand where our blank spots are, and start the lifelong journey of slowly expanding our rearview mirror view. As we grow in our self-awareness, it is important to listen, trust those who are directly affected by racism, and follow their lead!  

Landmark research papers on race, stress, and health, including several by distinguished Harvard School of Public Health Professor David Williams, support an expanded view on health care that includes the biopsychosocial model (Clark, Anderson, Clark et al., 1999). In this model, health care includes assessing and treating the physical body, as well as psychological and social health. This could look like:  

• A midwife or nurse asks their patient about past experiences of racism and how safe they feel in the hospital, in addition to measuring blood pressure – because they want a full clinical picture of the factors that may impact their patient’s blood pressure.  
• Doulas are not only trained in helping clients prepare birth plans, but also in preparing advocacy scripts to address racist comments in the birthing room. 
• Birth workers and health care workers work on self-awareness, changing their own racial biases, and becoming skilled at conversations with clients/patients about what they can offer to support their safety in the birthing room, or if they’d like a referral to a different birth worker/provider. 
• You actively understand what additional care you may need to offer Black, Indigenous, and birthing people of color to heal from harm, address red flags, and prevent/interrupt future harm.  

Here at Evidence Based Birth®, we would like to present the evidence on solutions and how we can expand our self-awareness and skills in interrupting violence in the birth room.  

We could spend one hundred pages writing about the research evidence on racism. But we don’t need more statistics on just the problem! Instead, we need evidence that will help us build our skills in advocacy and prepare us to recognize racism and react – whether that means speaking up in the moment, applying pressure to hold providers and hospitals accountable, or supporting Black, Brown, and Indigenous leadership in envisioning system change.  

This is what we want to do differently – to provide evidence that empowers, highlight research in a way that brings us to action, scripts for what to say when we see racism, and short and long-term solutions.

How to read this article

Certain sections of this article, such as Part 1: Solidarity & Soul Family, are written with a lens specifically for white birth workers, while others, such as Part 2: Afrofuturism in Birth, are designed to be educational for allies as well as empowering for Black and Brown people. We also acknowledge that people of color can show up for one another as allies as well!  

Feel free to skip around to different areas and handouts, based on your interests, background, and the emotions that arise as you read. If you start to feel discouraged or overwhelmed, skip ahead to the sections on solutions, action items marked in boxes, and the Afrofuturism and Equity Tools sections that highlight brilliant visionaries already making huge waves of change! 

The paper is divided up into 3 sections:

1. Solidarity & Soul Family
2. Afrofuturism in Birth
3. Evidence Based Equity Tools 

We acknowledge that racism and colorism exist globally, but the U.S. has a particularly racialized history, and so this Signature Article is centered on U.S. history and experiences. This article focuses on racism against Black people but offers evidence-based strategies to support human connection, empathy, and healing, which can be used to address violence, trauma, oppression, and harm across all communities. 

Led by Ihotu Ali, a valued member of our research team, this article was prepared with memory and honor for the hard, un/underpaid, and underappreciated work that Black women, trans and non-binary people, birth workers, caregivers, and leaders pour into their families and communities every day.  

Years from now, when we are asked what we did to answer the call of this time, we want to say that we did something – in collaboration, led by the voices of the experts and of the grassroots, and for the movement toward human rights and our collective liberation. We hope this work informs and inspires you in answering the calls of your heart, too. 

A note about language

We want to acknowledge the choices we’ve made around language in this article.  

Based on dictionary definitions as well as the voices of leaders of color in racial justice work, we’ve chosen to capitalize the words Black, Brown, and Indigenous as proper nouns that refer to specific cultural identities. In Rebecca’s book, Babies Are Not Pizzas, she also chose to capitalize these words.  

You may also notice that we chose not to capitalize the term white. Although there is a particular culture to whiteness, we want to emphasize that whiteness comes out of an assimilation process (a loss of cultural identity) that is designed and encouraged to maintain white supremacy, which is different than a historic and cultural sense of self born out of traditions, celebrations, and a connection with land and family. 

People who call themselves white in the United States today are the descendants of immigrant cultures from across Europe, and we believe that relocating white identity back towards our original cultures is a part of getting back to who we were in relation to each other and the land, before colonialism, slavery and the lure of owning land, owning people, and living in chronic, subtle competition divided and changed us. 

We encourage white readers to spend time learning about their pre-assimilation cultures, traditional foods, music and arts, and healing therapies that, in many cases, may have similarities with other Black, Brown, and Indigenous cultures, ways of healing, birthing, and raising our families.  

Pause, breathe, and notice your body’s response. 

We hope this decision to use language and capitalization will highlight the fact that the United States is not the only country experiencing racism, anti-Blackness, and colorism toward darker skinned members of our own population. We have learned from community leaders such as Anna Balagtas of the Pocket Doula, featured on EBB Podcast Episode #228, about the term “People of the Global Majority” to describe Black, Brown, and Indigenous people across the globe, who in fact are more numerous than those descended from Europe. 

You may notice other voices cited in this article have also made creative choices around language and capitalization, such as adrienne maree brown (also known as amb) who has shared that she prefers how lower case letters appear visually, that it challenges the automatic practice of capitalizing the self as capitalist commodification, and that “a word must prove itself worthy of capital.” Revered feminist writer bell hooks was also known for her choice to not capitalize her name so that the public would focus on her books and message, rather than her name. 

We also understand that there is debate and opposing views on language, and that like culture, it is always changing. We are open to the fact that we’re not perfect, we may not all agree, and we may change our views in the future. We do our best, but we also make mistakes! We learn by staying open to disagreement and discussion. We are glad to engage thoughtfully in the ongoing conversation of language, what we call ourselves and call each other, and how to make that process as empowering and respectful as possible! 

A note about revisions

We began working on this article in December 2021, and since that time it has gone through many revisions and sent to many different people for review and feedback. We have received feedback from EBB team members, EBB Pro Members and Instructors who engaged in the open-comment period, and expert paid reviewers (whom we acknowledge with deep appreciation in the acknowledgment section).  

We know we will fall short — that there will be sentences, paragraphs, and entire sections that you may wish included additional or different information. At the same time, we know that perfectionism is part of white supremacy culture. We tried our best to engage in excellence, reflection, and community building while writing this article, without falling into the trap of trying to be “perfect.”   

We made the choice to finally hit “publish” after 15+ months of labor, not because this article is perfect, but because it is good enough to be useful for birth workers and families, and because we know future editions can be revised as needed. If you would like to submit a note for our team to include in future editions, you can submit comments here [need link].   

A note about the icon used in the handouts

 The graphic icon used on the handouts and social media posts for this Signature Article was inspired by one of the Adinkra symbols, originally created by the Gyaman people, popularized by the Asante people of Ghana and still used today across the Black Diaspora. The Adinkra that we chose is called Eban, or “fence.” Eban is used to illustrate safety and security, the way a strong fence protects a home, and the way a strong love protects a family. Adinkra symbols, like symbols across many traditions, represent social values, proverbs, and cultural pride while on display at social gatherings and worn on fabrics, logos, and walls, such as at Emancipation Park in Jamaica. 

How do white cultures practice solidarity and family? (And what IS white culture?)

Some of us were taught in grade school that the United States is a “melting pot” of many different nationalities and cultures, many of whom willingly left behind their home countries and traditions to become “American,” for the hope of a better life.  

Historians such as Howard Zinn, author of A People’s History of the United States, teach us that U.S. history also included land theft, forced displacement, and attempted genocide of Indigenous peoples; stolen labor, enslavement, and torture and medical experimentation on African Americans; white Southerners who were willing to die in warfare to defend the right of white people to enslave Black people; treating women like property; protesting the right of women to vote; wrongful internment of Asian Americans who were also never fully admitted into whiteness; torturing and killing of LGBTQ+ peoples; discrimination toward Jewish, Irish, Italian, and Polish immigrants who were not initially seen as “white;” and discrimination against Latinx folks who are still told to “go back where they came from” – even when their ancestral roots go deeper into this entire hemisphere than those of descendants from northern Europe. 

 Pause, breathe, and notice your body’s response. 

Tema Okun, Kenneth Jackson Jones and others contributed to a widely shared public article and website titled “White Supremacy Culture – Still Here.” The article lays out particular cultural norms like perfectionism, the right to comfort, or fear of open conflict, that became rooted in U.S. society as most European immigrants assimilated into a broad white culture with values around “professionalism,” work outside of the home, financial success, and land and property ownership in the “New World.”  

In a famous and chilling interview with Charlie Rose, acclaimed author and beloved civil rights thought leader Toni Morrison points out how these “American” values often pit one community against another, celebrating competition over cooperation, and requires some to suffer for others to succeed. She asks:  

“Racism has just as much a deleterious effect on white people… If a racist white person doesn’t understand that [white people] are also a race… that it’s also constructed. But if I take away your race… all you’ve got is your little self. And what is that? What are you without racism? Are you any good? Are you still strong? Are you still smart? You still like yourself? 

If you can only be tall because someone else is on their knees, then you have a serious problem. And my feeling is, that white people have a very, very serious problem, and they should start thinking about what they can do about. Take me out of it.” 

 Pause, breathe, and notice your body’s response. 

 Another norm in modern white culture is the social “ideal” of a nuclear family and white picket fence. Regardless of our actual family or preferences, many of us have been taught to see in our mind’s eye, the image of two cis-gendered, heterosexual parents and their 2-3 children, with little attention paid to extended kin, and excluding elders from our households. It’s often assumed that kids drawing their “family” in school will include siblings and parents only, and COVID shutdowns also assumed that most households in quarantine would include a small number of people.  

But, from a global perspective, this is a relatively new and isolated cultural phenomenon. The Western/white nuclear family is described by Harvard anthropologist Joseph Heinrich, in his book, The WEIRDest People in the World: How the West Became Psychologically Peculiar and Particularly Prosperous. Heinrich and his research colleagues publish about the concept of the WEIRD mind (Western, Educated, Industrialized, Rich and Democratic) from studies they performed with undergraduate students who were also the children of academics. Their research found that this type of social orientation uses more of the brain’s left hemisphere and globally speaking, represents a relatively small population and new way of seeing the world that identifies less with family and ethnic groups… and feels less shared sense of collective responsibility. 

Pause, breathe, and notice your body’s response. 

In contrast, for generations and across many cultures, the idea of family has been large and inclusive of entire communities or neighborhoods, cousins, grandparents, aunts, uncles, nieces, nephews, niblings, neighbors, and longtime friends. Resources, time, and security/protection have historically been shared across the entire extended family.  

The idea of giving “everything” to ONLY your spouse and own biological/adopted children is not a universal cultural practice. Indigenous communities around the world use terms like “All Our Relatives” or “Our Mother” to show that family care and responsibility extends beyond the lines of biological lineage. 

Ihotu and Rebecca may not be biological family, but over the years have developed a relationship that is like “Soul Family” – those who are part of your soul’s purpose, preparing and raising you to achieve your purpose, dreams, or calling in life.  

Birth workers and healers encourage our clients to turn inward during the time of pregnancy, birthing and postpartum — this allows for deep healing, bonding with a baby, and building a family. We also witness over time how infants begin to turn outward again and need to explore, connect with others, and engage enthusiastically with life. 

Birth workers with children often feel burned out or forced to choose between time with their children and time in community… and many step away permanently from anti-racism and social justice work. This is exactly the moment when building an extended soul family could be transformational for both parents and children, by opening doorways to raising children in a village, with more support, connection, and protection.  

A word from Rebecca: A message for white readers on “allies” and “accomplices” 

I’ll never forget the first time a Black birth worker called me an ally. I had scheduled an Evidence Based Birth® “Be the Change” workshop in my former hometown of Memphis, Tennessee, and I worked with a local birth worker to make sure there were free and reduced-fee spots in the workshop for Black birth workers. In the end, more than half of the attendees were Black — a level of representation that was unusual for a white-led birth workshop in Memphis. 

During the workshop, I spoke openly about racism, white supremacy, my personal journey with uncovering the racism that lies within me, and how white birth workers in Memphis need to examine their own racial prejudices and biases and take action to support the Black-led maternal health initiatives in their own hometown.  

At the end of the workshop, one of the Black birth workers came up to me and said, “While you were talking, I was whispering to the other Black doulas around me. I said, ‘Oh my God, Rebecca is an ALLY!’ I was so excited, I wanted to jump up and give you a kiss!!” 

This was probably the best compliment I’ve ever been paid in my life. But it was also aspirational for me, and it motivated me to keep working. That’s because the word “ally” is not something I can ever call myself – instead, it’s something I should continually strive to earn. And furthermore, I should work towards becoming an accomplice – someone who is willing to make sacrifices, put themselves in harm’s way when needed, and do deeper self-reflection with themselves and others.  

Because white culture is so deeply rooted in professionalism and financial success, even when allies mean well and choose to make anti-racism work a central focus in their lives, they often end up making money and careers off of other people’s struggles. Their livelihoods are now tied to someone needing their “help,” when in this line of work, we should all be working ourselves out of our jobs! 

The Indigenous Action Network explains this in more detail in their article on Accomplices Not Allies: Abolishing the Ally Industrial Complex, as well as offering examples of allyship gone wrong that you can recognize and avoid, such as becoming a “Parachuter” or “Gatekeeper.” 

Pause, breathe, and notice your body’s response. 

Stepping outside the “white privilege” box: A whole new world 

White folks come to allyship for a variety of reasons. Perhaps you have a heightened awareness of justice or injustice. As a child, I was always noticing what was “fair” or “unfair” about how people were treated.  Maybe you have a family or friend member who is a part of an oppressed group. I have a disabled family member, and this has shown me a lot about how society creates “in” groups and “out” groups. Or maybe you’ve witnessed how racism has impacted friends and loved ones.  

Also, some people come to allyship because it’s the right thing to do — it makes society better for all of us and for future generations.  

The more you educate yourself about anti-racism, the more you’ll learn that racism and white supremacy hurts everyone. And, as many have written in the field of social justice, we should be working for co-liberation from racism, as our freedom is bound together. 

In the words of Aimee Brill, facilitator, birth justice activist and Co-Director of Village Birth International:  

“True allyship moves a person away from the trappings of individualism and invites a new way of experiencing collective care, equity, and trust – both of self and others.” 

As an ally/accomplice, I understand that “white privilege” offers superficial and material benefits. But there are deeper gifts in life that whiteness prevents me from seeing and experiencing.  

Just like fish can’t see water, white people can’t always see the culture they are living in. What if we were all attuned to the fact that there can be life outside of work, status, and money? Where our safety, our wounds, our emotions, our joy, our purpose, and our loving relationships matter at least as much as our productivity and goals? 

I am more than getting certain grades/education, being part of the “owning class” (owning a home and/or business) or being successful in the eyes of others… and by the way, these things were not earned, but rather came about because of the many doors inequitably opened to me because of my race.  

At the end of the day, who do I love? What do I care about? Who will be with me at the end of my life… will I die alone, or will I transition surrounded by the faces of friends, family, and a community that I love deeply?   

As a white person, I can’t change my race or the circumstances I was born into, but I can learn to re-order my priorities and self-worth into something deeper than race, education, status, ownership, or material accomplishment. I can define for myself what “privilege” is, what a “successful life” is, and choose what kinds of “power” I will respect and follow. 

To other white birth workers — let’s reach for the cultures and history we’ve lost and for teachers to share that history with us. Let’s welcome teachable moments in our lives to learn more about who we are as humans, in relationship with other humans, connected to the earth and all life… rather than the boxes society places on us. None of us truly fit in those boxes, though we can stay aware of the impact they have. 

Pause, breathe, and notice your body’s response. 

How do you start taking the first steps?  

I would argue that the first and most important step is to educate yourself, and become aware of the “invisible” cultural water that you swim in. 

One of the first things I did on my anti-racism journey was to put together a My Culture list (a simple Word document on my computer) to keep track of what values I was raised in, and to start to understand that not everyone might share these same values.  

Here are a few examples from my list: 

• Timeliness. 
• Being “polished.”  
• Instructing people to be “professional.” 
• Only allowing “proper” grammar or vocabulary. 
• Asking, “What do you do for a living?” or “What do you do for work?” This is founded in an emphasis on work/competition and interest in finding out the social status of the person you’re conversing with, to place them on the hierarchy.  
• Bland food, very little spices. 
• Only speaking English and complaining about people who don’t speak English. 
• Complaining about family members you’re going to see during the holidays (this is not something I personally do, but I witness white friends talking about this all the time, and it’s a common comedic trope on television shows and movies). 

• Wanting to talk to the manager.

• Feeling like you deserve the best in everything.

• Feeling like your children deserve the best in everything.

• Not liking noisy people; telling kids to talk quietly using an “inside voice”. 

• Talking about “good neighborhoods” and “good schools” (i.e. using coded language when talking about racial issues).

• Always having to be a “good girl” when growing up.

• Nostalgia about the past—vintage clothing, old movies, diners, returning to the times when we grew our own food, picked our own fruit—ignoring the fact that those same time periods involved violent oppression and atrocities committed against marginalized groups and not everybody could survive if they “went back” to the past!

My personal culture list goes on for about 5 pages, single spaced, and it is something I’ve been working on for years.  

I encourage you to take a moment right now to pause, breathe, and take out a pen or create a Word document to start writing down some of your own cultural practices and norms. 

Learning your own personal culture is critical because many institutions and workplaces in the U.S. (including schools, universities, hospitals, and businesses) value and normalize white culture over other cultures. Dr. Sayida Peprah taught me that this culture can also be called the dominant culture.  

Within the dominant culture, certain ways of communicating, working, and relating to others are expected and forced onto everyone, creating a stifling and harmful environment for people who come from other cultures.  

Not sure what I mean by dominant culture in the workplace? Here are some examples of what meetings looked like in the mostly white, mostly female nursing school where I used to work:  

• A written agenda is circulated by email beforehand.  
• The meeting takes place in a cold, sterile meeting room around a conference table.  
• If you come late you sit at a chair along the wall.  
• A white woman of high status oversees the meeting.  
• A lower ranking woman is assigned to take minutes (if it isn’t written down, it didn’t happen). 
• Although small talk may be tolerated for the first few minutes, it can’t go longer than that. 
• Meetings must follow Robert’s Rules (make a motion, second the motion, all in favor say “aye”). If Robert’s Rules are not followed, then the decisions are not official, and no action can be taken.  
• If someone raises her voice when she’s making a point, she is perceived as “too emotional” or “disrespectful,” and her supervisor might be told about it later.  
• There’s always someone who is visibly sick at the meeting (holding their head as if they have a headache, or coughing or blowing their nose), because taking sick time is discouraged.  
• Long boring presentations are made; along with tedious announcements that could’ve been communicated via email.  
• The meeting is officially “adjourned,” and some people leave alone… others leave in pairs to gossip or get the socializing in that they didn’t get to do during the meeting. 

Pause, breathe, and notice your body’s response. 

If this type of dominant culture meeting was boring and unremarkable for me (a white cis-gendered woman of medium social status at the time, surrounded by other white cis women), how would it feel to people who come from other cultures?  

Who decided that meetings would be like this? Whose voices are prioritized? Who decided who would be dominant, and who would be inferior or othered? What kind of hairstyles, communication styles, clothing styles, sounds, or movement would be tolerated in this space? Was, and is this a safe space for people of color? Is it a safe space for anyone? 

Not understanding dominant culture can contribute to the microaggressions that white people commit towards people of color. Microaggressions are defined by Dr. Kevin Nadal as “The everyday, subtle, intentional – and oftentimes unintentional – interactions or behaviors that communicate some sort of bias toward historically marginalized groups.” 

Microagressions may seem small and are often unintentional, but a 2020 study found that ”the cumulative ‘day-to-day stress’ caused by microaggressions has been reliably associated with negative physical and emotional health outcomes” including anxiety, depression, and poor self-esteem (Williams, Skinta, Kanter et al., 2020). And here at EBB, we have had many Black parents and birth workers tell us about microaggressions they experience in hospitals, clinics, childbirth education classes, doula trainings, and more.  

Can you think of a few common examples of microaggressions off the top of your head? How many examples can you think of?  

If you don’t know the microaggressions you might be committing, or are unable to witness them easily in others around you, how can you expect to be a safe person for someone of color, let alone an accomplice? 

I encourage white birth workers to pause and click here to learn more about microaggressions.  

Pause, breathe, and notice your body’s response. 

From building out your “My Culture” list, you may start to see the blank spots in your education – your next step then is to start filling them. Again, this is a marathon, not a sprint, because you will always have gaps and make mistakes. It’s okay to stay in a place of not perfect, and “always learning!”   

While educating yourself, do some deep internal work to dig out the cultural pieces of white supremacy that have embedded inside you, whether you asked for them to be there or not. I personally engage in self-work in three ways: 1) I journal about my anti-racism journey, using “Me and White Supremacy” by Layla Saad as a start, 2) I keep working on the “My Culture” list to learn about all the aspects of my culture (white, upper middle-class upbringing) that I take for granted, and 3) I talk with therapists and/or consultants to help me work through my anti-racism journey. This third option is not something many people can afford to do, but I believe it’s essential for me, since I am in a position of power/privilege as the owner and founder of Evidence Based Birth®.  

Finally, working towards being an ally includes taking a variety of actions in your daily life to interrupt the cycle of white supremacy and racism. I’ll give a few examples of actions I’ve taken: 

• My son was playing in a local Little League, and I noticed in the spring of 2021 that there were players with jerseys using “Indians” as their team’s name. I did a quick online search and found that the national Little League had stopped using this team name in 2020-2021, and that the Cleveland Indians were in the process of changing their name, which they (finally) completed in July 2021. I was shocked and horrified that in the fall of 2021, our local Little League was still referring to Indigenous peoples as a sports team name. I took 30 minutes to write an email to the director of the program, questioning why this team name was being used, explaining that Native Americans live in our state and that this would be offensive to Indigenous people attending our games. The director replied and thanked me for my letter and said that this team name would no longer be used next year. This change might have been made without my letter, but I thought it was important to educate the leader of the local Little League about the harm that they have been causing.  

Pause, breathe, and notice your body’s response. 

• I intentionally work to block fellow white people when they are gatekeeping. For example, when I was a nursing professor, I was interviewing a group of applicants to the nursing program. There were two faculty asking interview questions—myself (I’d been doing this for several years), and another white nursing professor (it was her first time helping with group interviews). The interview grade made up a substantial portion of a score that would determine whether the student was allowed into the nursing program. A few weeks later, during the admissions meeting, I noticed that my white colleague had scored the one Black student much lower than the other two white students who had been in their group of three. The white professor’s scoring had the effect of preventing the only Black applicant from joining the program. I argued insistently that the Black student had done perfectly fine on the interview, and that we could not deny her admission because of one professor’s score. It took me several times of raising my voice before the rest of the (all white) committee permitted the student to be admitted into the program. This was my first experience “seeing” the white gatekeeping that prevents more Black students from entering the nursing field. All that said, I try to also keep in mind that “gates” and my ability to open them is all a story created by our society! Some Black or Brown students may enter nursing school, but then struggle with the racism and dominant culture that they experience there, and question if they even want to work in medicine or finish nursing school. Some may not have these struggles. I don’t know what path is right for anyone else. I simply do what I can to keep informed choices open to as many people as I can, just like I do at Evidence Based Birth®. 

Pause, breathe, and notice your body’s response. 

• Other actions that I take include continually teaching myself, my adult family members, and my children about Black and Indigenous history (in our year of homeschool during COVID, I declared that the whole year would be Black history year, starting with the history of the African continent and kingdoms); talking in person with a school principal when I found out that they were using black jelly beans to symbolize “bad” in a class activity; making sure dolls/toys/books featuring Black or Brown children were available in class gift exchanges; educating my family not to ask “What do you do for work?” or “Where are you from?” or say “I slaved over that meal” (micro-aggressions) in social situations; supporting Black-owned businesses; buying fiction and non-fiction books from Black authors and Black-owned bookstores; recognizing my biases (this never ends); providing scholarships to EBB programs; making recurring donations to Black- and Brown-led organizations; studying both Spanish (to be a better neighbor to people in my community) and my own ancestral language of Dutch (to try and reclaim an ethnic identity that white supremacy culture stole from me and my family); and using social media to amplify the voices of Black and brown birth workers.  

Pause, breathe, and notice your body’s response. 

One of the amazing things about working towards allyship, is that the more you educate yourself, the more you act. And the more you act, the more confidence you gain in using your voice. Of course, I’ve stumbled and made mistakes. But we can’t let a fear of making mistakes prevent us from doing this work.  

As my son’s coach says, “Practice makes permanent.” If we all practice anti-racism faithfully, when teachable moments arise, we will start to see results. And it can also be contagious in a positive way! So many of our white members at EBB have mentioned to me that they have learned so much from our platform about anti-racism. I consider it one of my duties to educate as many white folks as possible about ways we can reduce harm, reject a culture of white supremacy, and work towards a more just world.   

Expand your Resiliency 

Many EBB members are already advocates and change makers, in their own ways. We also know that advocacy and allyship is unpaid work that can be labor-intensive, emotional, and draining.  

Burnout among activists is common, and many white allies have turned away from anti-racism practice over the trials of the pandemic and seeming competition of priorities like climate change, economic crises, gun violence, or the overturning of Roe v. Wade.  

This pendulum swing in public opinion is common in U.S. history, seen also after Reconstruction and the Civil Rights movement… but it is still extremely demoralizing for advocates and people of color to watch the outpouring of support for racial justice, followed by silence as the news cycle turns to other issues. 

The most effective and resilient advocates understand that the work of collective liberation is intersectional! All social justice issues are intertwined, and as the issues seem to pile up, it becomes even more important to work at the root causes, rather than chasing symptoms of disease.  

Many are realizing now that social justice work is not an add-on or an extra project for those who “have the time.” It is the path toward our collective survival, as more of us are touched personally by tragedies. How can we become even more committed to living our values, more self-aware of our blank spots, and more strategic so that we are working smarter, not harder? 

Consider setting aside 30 minutes to reflect and write down in a journal, or record into a voice memo, answers to these questions:  

• Is your solidarity and soul family, protection, and anti-racism practice where you want it to be? 
• Do you want solidarity to be a priority for you? Why or why not? 
• What would be lost for you, personally, if you cannot continue this work sustainably? 
• Are there any responsibilities or projects in your life that need to shift or pause, to make space for a regular anti-racism practice such as self-education, journaling, and reflection?

Pause, breathe, and notice your body’s response. 

Many of the anti-racist resources we reviewed include the following three key components. Continue your written or voice memo reflections, by answering these questions to deepen your anti-racism practice: 

• Do you have a regular anti-racism practice, where you reflect on your own culture(s) and biases? 
• Do you have a group of trusted friends or colleagues where you can have brave conversations to discuss your learning and how to speak up in moments where racism may be at play? 
• Do you break the color-silence to talk about justice in positive ways among your kids and family, your workplace, and your friends and social circles (in-person and online)? Do you support others whose voices also need to be heard? 

Pause, breathe, and notice your body’s response.  

Your Effectiveness 

Social justice researcher and author Dr. Barbara Love cautions that social change agents risk becoming demoralized and ineffective over time. One framework that can help is to keep a “liberatory consciousness.” As defined by Dr. Love: 

“A liberatory consciousness enables humans to maintain an awareness of the dynamics of oppression characterizing society without giving in to despair and hopelessness about that condition, to maintain an awareness of the role played by each individual in the maintenance of the system without blaming them for the roles they play, and at the same time practice intentionality about changing the systems of oppression.”   

Dr. Love teaches that developing this consciousness requires four steps: Awareness, Analysis, Action, and Accountability/Allyship (Love, 2018). As you read this section, think about which step you are currently engaged in!  

    Step #1: Awareness  

“It means noticing that the remark was made, and not pretending that the remark is harmless.” 

-Dr. Barbara Love 

A regular anti-racism practice can help to expand your awareness and your ability to notice social and racial nuances in the world around you. Because open racism is considered taboo, subtle microaggressions can show up in color-silent spaces, where race is not explicitly mentioned.  

Those without life experiences in noticing racially nuanced behavior and non-verbal cues may completely miss the incident or may question or be reluctant to consider that it was racism. Some of us were taught to notice and speak out about racial cues to reduce racism, while others were taught to downplay race and maintain a color-blind attitude in hopes of reducing racism.  

Practicing awareness includes the work of noticing the realities of race more accurately — we cannot address a problem that we cannot see!

Pause, breathe, and notice your body’s response. 

    Step #2: Analysis

“Analysis will reveal a range of possible courses of action… Some possible activities will produce results that are consistent with our goals of justice and fairness while some will not.” 

–Dr. Barbara Love  

White people love to engage in “raising awareness.” But raising the awareness of yourself or people around you, is not enough. To be part of the change, we must move on to the next step, analysis.  

A strong analysis practice can include both self-reflection and group discussion. Building community and conversation around social change can help you practice analysis and receive feedback around your expanding social awareness.  

Did you know that Albert Einstein joined the NAACP in 1946 and spoke publicly in support of the civil rights movement? As a Jewish person and target of anti-Semitism in Germany, Einstein was aware and sensitive to the dangers of racial injustice and white supremacy. He purposefully developed friendships with U.S. civil rights activists including Paul Robeson. The community that Einstein developed around solidarity and shared values led him to learn the nuances of U.S. racial inequities, and to speak up and use his influence at key trials including the Scottsboro Boys Case.  

Pause, breathe, and notice your body’s response. 

    Step #3: Action

“

“Sometimes it means taking individual initiative to follow a course of action. Sometimes it means encouraging others to take action. Sometimes it means organizing and supporting other people to feel empowered to take the action that the situation requires.”  

– Dr. Barbara Love  

Taking action for racial justice can start with simple “teachable moments” with the people already in our circles of influence – especially young people!  

Many white parents are hesitant to talk to their kids about race, but our society is already embedded with messages from media (books, television shows, advertisements) showing white people as heroes and heroines, and dark-skinned characters as sidekicks, comic relief, or at worst, evil or dangerous. For example, think back to the “Lion King.” Which lion was the heroic king, and which one was the evil king?  

In 2005, researchers carried out a study to investigate if racial bias is innate or learned. Their research showed that newborns are essentially born “colorblind,” but by around 3 months, infants already start showing a preference for faces that share the race of their primary caregiver (Kelly, Quinn, Slater et al., 2005).  

Depending on the diversity of people that children are exposed to in early life, race can become an early marker for what feels familiar and safe. Neuroscientist Dr. Larry Sherman and early childhood expert Diane Haulcy agree that there is a hidden danger to ignoring or side-stepping children’s questions about race – this develops stigma and suggests they should avoid asking about a topic they are naturally curious about.  

Pause, breathe, and notice your body’s response. 

Pause, breathe, and notice your body’s response. 

Pause, breathe, and notice your body’s response. 

    Step #4: Accountability & Allyship

“A Person of Color will often have a perspective or ‘window of understanding’ that is unavailable to a white person because of the latter’s socialization into whiteness.… Similarly, a Person of Color can become stuck in patterns of internalized racism and left alone to struggle… The same holds true for men addressing sexism and women addressing internalized sexism, as well as for “owning-class” people, those raised poor, and working-class people who are concerned with classism… But working in connection and collaboration with each other, across and within “role” groups, we can make progress in ways that are not apparent when working in isolation and in separate communities.” 

– Dr. Barbara Love 

The groundbreaking book, Birthing Justice, edited by Julia Oparah and Alicia Bonaparte (@blackwomenbirthingjustice), highlights the international crisis in health care for Black women and birthing people by sharing the voices of academics, birth workers and personal stories around the globe. This book elevates often unheard leaders into the center of debates over how to fix broken health care systems and reminds us that Black women and birthing people who directly experience the problems are needed in leadership as we work toward solutions.  

Dr. Love, and efforts like the #CiteBlackWomen movement remind us that, if we do not work collaboratively to elevate certain voices, their expertise and solutions may never be brought into the mainstream, where they could positively impact health care and childbirth for us all. 

The truth is, we already have a blueprint to follow that can change many of the tragedies and challenges faced by families from the effects of racism in pregnancy and childbirth—and this blueprint has been designed and authored by Black, Brown, and Indigenous midwives and birth workers. Models of care led by Black midwives have been shown to eliminate racial inequities. Evidence published by Black researchers show that racially concordant care—when families are cared for by a provider who looks like them—can offer a much more positive picture for families of color (Greenwood, Hardeman, Huang et al., 2020).  

We know there are solutions (they will be featured in depth later on in this article, in case you don’t know them yet). What we don’t have so far is enough amplifiers and momentum to make these solutions into reality. This is where your solidarity is needed! 

Pause, breathe, and notice your body’s response. 

Welcome to Part 2!

Welcome to Part Two of a three-part series on the Evidence on: Anti-Racism in Health Care and Birth Work! We encourage readers to explore these sections at your own pace and by areas of interest, but it will be helpful to at least read the Signature Article Introduction, available at ebbirth.com/antiracism, for context and an explanation of the body awareness reflections you will encounter in Part 2: Afrofuturism in Birth.

In both Part 2: Afrofuturism and Part 3: Equity Tools, you will meet Black visionaries who are not only fighting against racism and disparities, but doing so in futurist ways that shift the narrative back to joy, healing, and excellence. As a white-led organization, our goal is to amplify these voices, and get out of the way! This article went through several internal and external reviews and we made a special effort to not only include leaders with large and public platforms, but also leaders who work more offline with a strong local impact, and who may need extra support to access funding and national attention. There are also leaders we didn’t have space to name here, including from other cultures, and those outside of the United States. The champions we weren’t able to name here still deserve support, funding, and recognition.

We chose to focus on Black leadership and Afrofuturism because of the ongoing anti-Blackness in birth work, but we recognize that Indigenous birthing people also face deep racial disparities and health concerns unique to their community and history. Please help us highlight Black, Brown, Indigenous, and intersectional birth workers in other ways:

• Visit the Birth Justice page on the Evidence Based Birth® website, where we feature Black, Brown and Indigenous-led birth work organizations across the United States.
• At the bottom of that page, you can submit suggestions for additional organizations to be featured (including outside of the U.S.) – or simply email info@evidencebasedbirth.com.

Pause, breathe, and notice your body’s response. 

Pause, breathe, and notice your body’s response. 

The Black Birthing Bill of Rights®, was created by the National Association to Advance Black Birth (@thenaabb) and illustrator Angelica Marie (@wearekarasi), as a set of illustrated patient rights and affirmations. You can read the entire bill of rights on the NAABB website, www.thenaabb.org, download a PDF, and learn more about this powerful visual to share with Black birthing people. You can also ask your local health care centers to clearly post a copy in waiting rooms and patient areas!

With permission from the NAABB, we selected six principles from the full Black Birthing Bill of Rights® to adapt into Table 1 below, and we added research, advocacy, and action items for each topic. Our hope is that this Table can give examples of specific action steps to make the Black Birthing Bill of Rights® a reality in the years to come.

When we consider the entire problem of racism in health care and birth all at once, it can seem huge and overwhelming! The Black Birthing Bill of Rights® is an antidote against “analysis-paralysis,” and it can guide our work into smaller, manageable parts. Based on your own individual skills, connections, and areas of passion, feel free to use (and share!) this Table to inspire at least 1-2 action steps to integrate into your advocacy.

Pause, breathe, and notice your body’s response. 

Pause, breathe, and notice your body’s response. 

Black Visionaries in Birth History, Arts & Culture

Let’s turn now to visit Black visionaries in history, arts and culture. In Black cultures, art has always been, is currently, and will always be present. Art may include storytelling, space for Black joy and rest, or a gateway for healing and spirituality. Whether songs from the Blues and Jazz traditions, African wooden masks and jewelry, or Southern Hoodoo (ancestral religion) ceremonies and altars, art in Black and African American traditions serves many purposes. The use of art in Black Birth Futurism continues this practice of using art to advocate, educate, and heal.

Pause, breathe, and notice your body’s response. 

Legacy Power Voice: Movements in Black Midwifery” is a documentary collection of first-hand testimonies of trailblazing Black Midwives that explores the evolution of Black birthing traditions in the United States. Presented by the National Black Midwives Alliance, created by Director/Cinematographer/Editor Karyl-Lyn Sanderson, and Executive-produced by NBMA co-founder Jamarah Amani, this powerful documentary is currently crowdfunding and looking for support!

Pause, breathe, and notice your body’s response. 

Pause, breathe, and notice your body’s response. 

Attorneys for the Johnsons say they are adding additional violations under the Unruh Civil Rights Act and taking depositions from Cedars-Sinai employees, who have witnessed people of color being treated differently than white patients. One of their attorneys, Chris Dolan, speculates on the potential impact for this lawsuit, saying: “As this lawsuit proceeds forward more will be exposed, and hopefully what it’ll do is send a message to other hospitals and healthcare facilities that if you discriminate on the basis of someone’s color, we’re coming for you.”

Kimberly Seals Allers, journalist, author and creator of the Irth App, also created the “Birthright” podcast in order to tell stories of healing and joy, to overcome the potential for “doom and gloom” amid all the increased awareness of challenges that Black birthing people face, and to share resources for mental health and trauma healing. There are also several other podcasts focused on birth stories from people of color, that you can check out in our Birth Justice resource page!

Erica Chidi, CEO of sexual and reproductive health educational platform, LOOM, teamed up with Dr. Erica Cahill at Stanford University’s Obstetrics and Gynecology to write New York Times article, Protecting Your Birth: A Guide for Black Mothers. At the time the article was published, there were few resources available to help Black birthing people navigate pregnancy in light of possible racism. So, they created a guide to answer common questions about preventing racism through pregnancy and children, including special attention to the increased risk of preeclampsia, high blood pressure, and likelihood of insufficient pain relief that many Black women face. The article is also written with sections for care providers and includes links and suggestions on ways to reduce bias in the birth room, from a provider perspective. This article is also summed up into a one page Antiracist Prenatal and Postnatal Preferences handout here. 

Master Doulas like Denise Bolds and Michelle Gabriel-Caldwell know all too well the negative impact that statistics without solutions can have on families. As Black doulas who have each attended hundreds of births, Denise and Michelle have witnessed Black families become even more fearful of giving birth, as public awareness of the U.S. Black birth crisis has grown.

Denise Bolds, also known as “the high risk doula,” is a published author and public speaker, radio and podcast producer, and former President of DONA International. Her tireless support and advocacy for Black and Brown families through the epicenter of the pandemic in New York City was featured in the New York Times. 

Michelle Gabriel-Caldwell  is a Doula Trainer and Advisory Board Member of the National Black Doulas Association (NBDA), Doula Coordinator at The Birth Center of New Jersey, and in leadership roles at the New Jersey Infant and Maternal Health Advisory Board and Perinatal Health Equity Initiative. She has worked in maternal health, policy and advocacy for over 18 years, in addition to being a chemical engineer, and also has been profiled by the New York Times for supporting Black families and teaching childbirth classes with her husband, Brent Caldwell.

Clearly sharing a passion for educating families, both Denise and Michelle are Evidence Based Birth® Instructors and played a critical role in equity and birth justice conversations at EBB. In response to a request from Rebecca, Denise and Michelle teamed up and contracted with EBB to prepare a special education feature for Black families, from Black doulas on the frontlines.

Now available as part of the Evidence Based Birth® Childbirth Class, this customized seminar on Black Birth features Denise and Michelle talking candidly about facing your fears around giving birth. They discuss choosing your provider and building community and family support, navigating high risk births, informed consent, healing and recovery after birth. They explain specific red flags to look out for, such as shortness of breath, advocating with providers who may dismiss your concerns, and ways to protect yourself through rest, holistic care, Black breastfeeding and mental health support. The Black Birth Seminar is an excellent resource for all EBB Instructors to share with their students and clients to open up courageous and important conversations before giving birth.

Pause, breathe, and notice your body’s response. 

Still today, many Americans have no idea that current vaccination and Cesarean section techniques were developed from methods learned from Africans and folk healers. Living through the Atlantic slave trade, chattel slavery, forced migration, and racism created obvious conditions for people of color to become resourceful and inventive problem-solvers for their own survival. A few more examples of innovations from the African diaspora that developed under harsh conditions include:

• The Soul Food tradition—a delicious remix of leftover animal parts discarded from slave masters.
• Brazilian Capoeira evolved as a way for slaves to teach one another martial arts disguised as dance.
• Grand Midwives under persecution learned to hide their herbs and tinctures in a hidden flap at the bottom of their birth bags!

Today, Black visionaries in technology use the internet and apps to share information, connect people globally, and use the power of mass communications for truth telling and improving health care.

Pause, breathe, and notice your body’s response. 

With data as a leveraging tool, the Irth team can build partnerships and work directly with hospitals and expand their internal Quality Improvement (QI) efforts to include improved care for Black and brown birthing people.

“What does it mean when we’re seeing people constantly saying their pain levels are being dismissed, or frequency of some of the negative practice behaviors that are common in Irth? Is that empathy training? Is that more accountability in terms of from the hospital employers and human resources? What will it take? Hospitals have created a whole mechanism around quality improvement, but none of it has been rooted in an understanding of what that means to Black people, to Black birthing folks.”

-Kimberly Seals Allers, EBB Podcast Episode #220 

Irth is available across the United States, but the most reviews so far are in New York City, New Orleans, Los Angeles, Sacramento, the Bay Area, DC, Atlanta, Detroit and Chicago. If you are birthing or attending births in these cities, look our for Irth posters, providers wearing Irth buttons, or cards in your discharge folders. Whether you are a midwife, doula, or birthing person, consider completing an Irth App review for every birth experience as a standard part of postpartum care and follow up. It is especially powerful when doulas leave reviews, since they attend births across multiple providers and locations!

Mahmee is a maternal healthcare company dedicated to improving birth outcomes in historically marginalized communities and empowering all families with wraparound support during the pregnancy and postpartum period. Available as a mobile app, online, and with in- person services offered in Los Angeles, Mahmee offers an all-inclusive, unlimited care subscription for mothers and birthing people, and outcomes-based programs to health systems and payors to better meet the needs of diverse populations.

The Mahmee Membership, Mahmee’s subscription offering, gives patients access to their own care team of nurses, lactation consultants, mental health coaches, nutritionists, care coordinators and doulas, — there for patients seven days a week, at home, virtually, and in Mahmee in-person clinics in Los Angeles. Mahmee partners with government agencies and insurance companies to make their comprehensive support package completely free for those who would normally not be able to afford it on their own.

In addition to pairing patients with a multidisciplinary team, Mahmee also offers critical resources, including virtual support groups and class, health monitors, and over 300 evidence-based educational articles, available in both English and Spanish.

Mahmee’s services are uniquely robust during the postpartum period – when required medical visits are less frequent, when some birthing people may lose public health insurance, and it becomes more challenging to leave home to attend appointments. According to the Commonwealth Fund, 17% of all pregnancy-related deaths in the U.S. occur on the day of delivery, meanwhile over half of the deaths occur in the days and weeks after delivery due to severe bleeding, high blood pressure, infections, and heart complications (Tikkanen, Gunja, FitzGerald et al 2020).

According to the company, Mahmee patients are 10% less likely to have a Cesarean and nearly 50% less likely to give birth preterm, compared to national averages. Cases of postpartum hemorrhage and mental illness have been caught early and flagged for providers’ care with success. “Black and Indigenous birthing individuals are represented in Mahmee’s population at three times the rate of the U.S. birth census,” says Mahmee’s Co-founder and CEO Melissa Hanna, “and yet Mahmee’s birth outcomes are much better than the national average, which demonstrates that the country’s maternal healthcare disparities are solvable.”

The emerging startup made waves by raising over $13 million to date. Its series A round was led by Goldman Sachs Asset Management as part of their One Million Black Women incentive to address the dual disproportionate gender and racial biases that Black women face. Mahmee’s funds also include over $3 million from well-known names and investors including Serena Williams, who was described as emotional when meeting the founders, realizing that it was run by a biracial woman (Melissa) and her white mother (Linda). Mahmee is also backed by Muse Capital, Backstage Capital, MaC Venture Capital, Episcopal Health Foundation of Texas, Mark Cuban, and others.

Pause, breathe, and notice your body’s response. 

JustBirth Space initially started as an online resource for pregnant people in New York City and New Jersey through the COVID-19 pandemic, as a partnership among BIPOC, Jewish, and Queer birth workers, and organizations including Village Birth International, Ancient Song Doula Services, Jacaranda Health, and Every Mother Counts. Still growing strong, over 4,000 people around the U.S. have now used Justbirth Space and its three Circles of Care:

1. TextConnect: Immediate answers to any questions about pregnancy or lactation.
2. WeConnect: Phone or video support for more in-depth prenatal or postpartum care.
3. CommunityConnect: Weekly online classes and peer support groups for building skills and community around pregnancy, parenting, lactation and mental health.

From 8am to 10pm Eastern Time, you can text 646-681-1648 to reach an intersectional team of BIPOC, Queer, Disabled, Spanish-speaking doulas and lactation consultants or non-judgmental support and compassionate, full-spectrum care at no cost. JustBirth Space is a model of virtual perinatal support with the long-term vision to integrate holistic and responsive support into the maternity care system. With accountability as a core value, JustBirth Space has built a diverse team of providers, wide network of referral partners, and pathways to deepen accountability and guide healing for birthing people, doulas and birth workers, and hospitals and health care systems.

Social media has provided a platform for birth workers and birthing families around the globe to connect, share stories, educate, offer cautions, and collaborate. Whether they have 200,000 or only 200 followers, they are making an impact! We want to take a moment here to highlight a few social media savvy birth workers who are using social media in unique ways that we all can “follow”:

• @theblackobgynproject on Instagram: Dr. Rachel Bervell and Dr. Tamandra Morgan created an online community of Black medical graduates they met while interviewing for OB/GYN residencies. Their page features public education campaigns on topics from hypertension to endometriosis, mentorship opportunities, and truth telling about the history of slave experimentation in their profession. Listen: EBB Podcast #174: The Need for More Black OB/GYN Representation with Dr.Rachel Bervell and Dr. Tamandra Morgan.
• @doctormidwife on Instagram: Midwife Stephanie Mitchell educates through humor on racial dynamics in the birth room, mobilizes funds and political support, and exposes challenges as she builds a new birth center, The Birth Sanctuary, in Gainesville, Alabama. Listen: EBB Podcast #181: Restoring Black-led Nurse-Midwifery Care in Alabama with Dr. Stephanie Mitchell.
• @iamn0tthe1 on Twitter: Michelle Drew is a Delaware-based midwife, obstetrics residency educator, and the Executive Director of the Ubuntu Black Family Wellness Collective. She pinned a tweet at the top of her page with an “essential reading list” that she gifts to all incoming residents and recommends for all white OB-GYNs working with Black patients.
• @birthworkersforhumanrights on Instagram: This white ally/accomplice-led page reposts campaigns and requests by Black and Brown birth workers and provides advocacy support.
• @birthmarkdoulas on Instagram: This collective of doulas in New Orleans posts informational resources for their local birthing community around events, birth and lactation services, and emergency preparedness through hurricane season, and more!
• @oilydoulamn on Instagram: Rhonda Fellows is a Minnesota-based Black doula trainer, EBB Instructor, and created the Community Aware Birthworker Training. Rhonda used her online platform to ask hospital staff members, nurses, midwives, and OBGYNs if they had seen the Aftershock documentary on Black maternal health, and what their places of work are doing as a response, to open up important conversations! Listen: EBB Podcast #141: Birthing and Disparities in Minnesota with Rhonda Fellows and Dr. Jennifer Almanza.
• @Clarabelletoks on TikTok and Instagram: Brilliant and hilarious reels of scenarios imagining what if European-Americans were the cultural “other”; uses humor to educate on microaggressions and sexism.
• @FlowerinSpanish on Instagram: Activist Flor posts powerfully in support of immigrant reform and the abolishment of ICE (U.S. Immigration and Customs Enforcement).

Pause, breathe, and notice your body’s response. 

This the End of Part 2.

Please return to the top of this article to download supplementary handouts and read Part 1 (Solidarity and Soul Family).

Part 3 (Equity Tools) will launch April 26th.

Part 3: EVIDENCE BASED EQUITY TOOLS

In Part 3 of our Signature Article on the Evidence on Anti-Racism in Health Care and Birth Work, we focus on evidence based equity tools. You can read Part 1 (Introduction + Solidarity and Soul Family) and Part 2 (Afrofuturism in Birth) via the buttons at the top of this page.

In April 2022, Florida Governor Ron DeSantis signed the first U.S. state law to make diversity, equity and inclusion (DEI) initiatives illegal across public universities. The “Stop WOKE* (Wrongs to our Kids and Employees) Act” puts restrictions on teaching anything that could cause “guilt, anguish, or other forms of psychological distress” related to someone’s race, sex, or national origin. Across the United States (U.S.), academics and advocates are following this case closely because Florida is known as a “testing ground,” where what happens in Florida often spreads around the nation.

*It is both ironic and saddening that the “anti-wokeness” movement co-opts a term that has traditionally been used by the Black community for nearly 100 years to remind each other to stay “woke”— to keep your eyes open and be wary of the life-threatening risk of racism in the U.S.

Racial justice movements in the U.S. have historically been followed by periods of backlash where counter-protestors arise and actively work to stop the efforts of racial justice advocates (Patterson, Santiago, and Silverman, 2021). We see this in examples like the Florida DEI ban, and the College Board’s decision to remove critical race theory, Black Lives Matter, queer theory, and Black feminism from the Advanced Placement African American Studies curriculum.

Even though it can feel frustrating and demoralizing, a backlash often appears after periods of rapid social change. This is not new to 2020s, and it shows just how much change has occurred recently, that opponents are fighting these changes with so much force.

There will always be those who disagree with and oppose social change movements. But it is even more demoralizing when advocates realize that their peers or allies are not skilled enough to recognize half-hearted efforts or co-optations present within their own community. For example, when we don’t fully agree that racism is a public health hazard, we can fall into half-hearted attempts where we uplift equality rather than equity, diversity rather than anti-racism, or we measure progress by projects rather than by outcomes.

This final section of the Evidence On: Anti-Racism in Birth Work and Health Care is designed to highlight equity tools most supported by the current evidence. We also hope to provide cautionary tales and share nuance, so that birth workers can understand how equity tools could be used for personal gain or reinforcing systems instead of collective liberation. Advocates, please read this section carefully to build on the skills and insight needed to ensure that equity tools are used for equity.

Equity vs. Equality

What is the difference between equality and equity?

Equality is each person receiving the same treatment, information, resources, and opportunities, while equity is each person receiving what they need to arrive at the same outcomes.

Working toward equal treatment of Black and white patients is important, but equitable outcomes is also something that motivates us as advocates and changemakers.

Evidence shows that Black patients receive less time and shorter visits with doctors, even though they experience higher risks due to the complications of the Racial Weathering Effect (Geronimus, 1992).

But in many cases, birthing people of color may need more support and time with a provider, if they are experiencing more fear, complications, or have more questions than white birthing people.

You could look at it like this: If someone experienced a series of surgeries due to multiple car accidents, we would expect a doctor to review their medical history with extra attention… anticipating more pain, sensitivity, and possibly a longer healing process after any future surgeries. We would expect their doctor to not waste time blaming a patient for having gotten into so many car accidents, and we hope they would have empathy and offer whatever care is needed. Perhaps the provider would offer new and innovative treatments, even if it takes up more of their time or is outside of the “normal” treatment plan. A doctor might need to appeal for extra help, training, or more time to be with this patient, and hopefully their clinic administrator would advocate on their behalf, for quality care for this patient.

On a systems level, a similar level of racial equity in health care might look like offering customized care and additional training to providers working with communities of color and those with health inequities, given their higher risk medical history.

In a nutshell, a movement towards equity is a movement towards increasing or enhancing the standard of care. Health care workers have started working towards making equity a priority in cancer care and other fields, and we can choose to make it a priority in birth and obstetrics.

Bringing equity to health care for pregnant families may take more resources and creativity. It also takes passion to find ways to raise and manage resources. But we believe this extra effort will be well worth it. It may save lives, change lives, and change the social dynamics of future generations, so that everyone—all our descendants and loved ones—will benefit.

On the other hand, when providers see racism as only a social problem (or maybe even as an exaggeration or falsehood), rather than a legitimate part of someone’s medical history and risk exposure, it becomes easier to think of their pain and need for extra care as unnecessary, as a handout, or as an annoyance.

Diversity vs. Mending Broken Relationships

Celebrating diversity is an important step in anti-racism work, but allies who are not skilled in seeing the harm of racism may fall into promoting diversity and self-education, rather than promoting healing and culture change.

For example, a hospital can hire Black nurses, but continue to allow substandard care for Black patients.  A white doula can join a book club and read dozens of books on anti-racism, but might be intimidated to reach out to Black families or doulas in her neighborhood to ask what support they need.

Just like the patient with the history of multiple car accidents, families and doulas who have experienced racialized trauma may express more pain and intense symptoms, ask more questions, and ultimately need more time and support than a solo white doula can currently offer. But what if that doula could collaborate with a group of doulas, or partner with a nonprofit organization, so that when the client signals that they need help, the doula will be less overwhelmed and more equipped to respond?

Healing cross-racial relationships is not easy. It takes a willingness to acknowledge the pain and anger that still exist as elephants in the room. And the intensity of this work can surprise fair weather allies who never fully understood the nature of the problem.

Regardless, we hope the information below will help committed advocates to prepare and become savvy around anti-racism in the same ways that we educate birthing people to get savvy about birth! And when the going gets tough, don’t give up your anti-racism and equity efforts—keep going! Just like we discussed in Part 2: Afrofuturism—keep your thoughts and imagination centered on what birth could look like!

In Part 3 of this Signature Article, we are going to review the top three equity tools supported by the research. We will also provide concrete examples of how these equity tools can be put into practice, as well as cautions to train your eye and learn from hard lessons of the past.

The Evidence Based Equity Triad

In our Evidence Based Birth® Childbirth Classes, we often teach about how evidence-based care is a 3-legged stool, with the “legs” of 1) accurate, evidence-based information on all of your care options, 2) a provider who is familiar with the evidence, and 3) asking about and honoring the client’s values, goals, and preferences. A stool with only one or two legs cannot stand, so it takes all three essential legs!

Similarly, through the course of our research, we found that equity solutions proposed by Black leaders and visionaries tend to fall into three main categories. The Evidence Based Equity Triad in birth work can include:

There are other EBB resources and Signature Articles on these topics that we will refer to for more information, but here is an overview of each, and highlights on areas that need additional support to have a greater impact!

On this topic, the evidence is robust and clear – compared to the medical model, midwives and the midwifery model of care provide safer alternatives for women and birthing people of color. You can listen to EBB Podcast Episode #175 to learn more about overall evidence on midwives, and this section will focus especially on the impact of midwifery care in Black, Brown and Indigenous births.

Let’s walk through some recent statistics you can use to explain why it’s important for birthing people of color to also have equitable access to midwifery care.

In 2019, Vedam et al. published The Giving Voice to Mothers study, including more than 2,000 people who gave birth between 2010 and 2016. They found that one in six, or 17%, experienced one or more episodes of mistreatment. Indigenous, Hispanic, and Black individuals were at least twice as likely to experience mistreatment, but giving birth in a community setting (home birth or freestanding birth center) lowered all participants’ risk of being mistreated during birth. Among women of color who gave birth at home or in birth centers, only 6.6% (one in twenty) reported any mistreatment, compared to 34% (one in three) who gave birth in hospital settings.

Data from the Irth App also show that hospitals that have implemented any kind of midwifery model of care tend to receive more positive reviews from Black patients (EBB Podcast Episode #220). This suggests that people of color are less likely to experience mistreatment when they receive care from midwives. Although the field of midwifery in the U.S. is still mostly white, and midwives are not immune from perpetrating racism, the evidence points to midwifery care being a safer option with potential to reduce racial health inequities.

As a profession, midwives are taught to work in partnership with families in a more equitable model of care than in many standard medical or nursing schools. White ally/accomplice midwives have created innovative resources such as the Equity in Midwifery Education Project that offers webinars and CEUs on creating anti-racist curriculum and clinical experiences for students.

At the other extreme, white midwives and historically white associations such as the American College of Nurse-Midwives (ACNM) and the North American Registry of Midwives (NARM) also have a history of gatekeeping and not responding at all (or having delayed responses) to open letters, calls for change, or public debates on racist remarks made by white midwives. These are missed opportunities to speak up in support of equality, in defense of all midwife members, and to set the tone for the entire profession.

A few challenges remain before midwives can reach their full potential in impacting equity:

• Midwives in the U.S. attend only about 9% of births, in contrast to other countries where they make up most of the obstetric care workforce, outnumbering obstetricians 3 to 1 (Declercq, 2012). (In the U.S., there are nearly four times as many obstetricians compared to midwives.)
• Midwives face institutional and legal challenges, including unnecessary restrictions on their scope of practice, based on their type of training. Some states only license midwives who are also trained as nurses first (in contrast to most of the rest of the world, where midwives do not typically train as nurses). Community efforts to license midwives are still ongoing; only in the last five years did Kentucky (2019), Hawaii (2019), Oklahoma (2020), DC (2020), and Illinois (2021) pass legislation to legalize Certified Professional Midwives! And legislation can be quite flawed, sometimes limiting families’ autonomy or not permitting Medicaid reimbursement for Certified Professional Midwifery care.
• Not all hospitals hire midwives and, even then, midwives are looked down upon compared to doctors. Home birth midwives may struggle to feel integrated into the broader health care system and many are not accepted by health insurance or face low reimbursement rates. Do you know how welcoming your state and local laws, hospitals, and insurance companies are to midwives and the full scope midwifery model of care? Are the policies and reimbursement rates equitable across ALL types of midwives (Certified Nurse Midwives, Certified Professional Midwives, and more)?
• The field of midwifery is mostly white, despite its origins among Black, Brown, and immigrant midwives in the early 20th century. According to a 2019 report from American Midwifery Certification Board, 87% of certified nurse midwives and certified midwives identify as white, while 6.3% identify as Black or African American. Even though innovative groups like Melanated Midwives, the National Black Midwives Alliance, and the National Association to Advance Black Birth offer scholarships for midwives of color, they need much more support to turn this national trend. Here’s why:

In the early 1900s, midwives were still providing safer care and had lower maternal mortality rates than physicians, but obstetricians and allied medical and public health professionals, including nurses, devised a three-pronged approach to take over the market. They launched a national propaganda campaign to convince the public that midwives were dirty, foreign, and ignorant.

You can read an excellent article by Dr. Mimi Niles and Dr. Michelle Drew, both certified nurse midwives, about how white supremacy led to a midwifery workforce in the U.S. that is largely white. The article is called “Constructing the Modern American Midwife: White Supremacy and White Feminism Collide”. In this article, they outline the history of midwifery in the U.S. and talk about Mary Breckinridge, who many considered to be the “mother of nurse midwifery” in the U.S.

One way to increase the number of midwives in the U.S. overall, and especially Black midwives, is to uplift and expand more training programs led by Black midwives. Florida-based midwife Jennie Joseph, one of TIME Magazine’s 2022 Women of the Year, runs an innovative clinic, birth center, and the only MEAC (Midwifery Education Accreditation Council)-accredited, Black-owned private midwifery training school in the U.S. (at the time of writing). Tanya Smith-Johnson is the first Black President of the National College of Midwifery in New Mexico. These midwives are phenomenal leaders whose work we can get behind, but they should not be the “firsts” or the “onlys”!

A 2017 report showed that Jennie Joseph’s model, the JJ Way® Maternity Care Model, nearly halved preterm birth and low birth weight rates for Black families. Under her care, Black birthing people had a preterm birth rate similar to white birthing people in Orange County and in the State of Florida — the racial disparity in preterm birth rate was eliminated!

Jennie Joseph speaks about her model as accessible to anyone regardless of their ability to pay, race, or health status, and offers powerful stories and wisdom in EBB Podcast #136: Solutions for the Crisis in American Maternity Care with Jennie Joseph. She also hosts the National Perinatal Task Force, where she encourages advocates to create and support Perinatal Safe Spots and where families located in high risk or materno-toxic areas by zip code can find respectful care. You can visit her website to find organizations around the country that are designated Perinatal Safe Spots. If you are in the U.S., look up ones near you and reach out to support and expand their work!

There are dynamic, highly experienced Black midwives around the country who would open more midwifery schools if fewer barriers existed. For example, Sakina O’Uhuru, Certified Midwife and Physician Assistant, has been providing care to families since 1984, and is the author of Journey to Birth and Executive Director of A Wombman’s Way Warrior Midwife Training. This community-based midwifery training is designed for Black midwife students, taught by Black midwife faculty, and includes virtual and flexible attendance options to accommodate adult learners. The program intentionally works against barriers to entry by offering an accessible application enrollment process, and a curriculum that is anti-racist and focuses on accountability, leadership, and preserving the legacy of “Gran Warrior Midwives.”

Unfortunately, inequities and gatekeeping exist in the process of applying for funding as well as credentialing and accreditation for midwifery training programs. O’Uhuru has encountered systematic roadblocks, dead ends, and denials in her efforts to expand her training, offer scholarships, and receive accreditation from MEAC and other certifying bodies. The program relies on support from private donations (which you can support here) but O’Uhuru and other midwives could also benefit from changes in policy and administrative systems to streamline the process of opening and funding new midwifery education programs.

What about midwives in birth centers or other community spaces?

In 2020, there was an exciting development around Black- and Brown-led birth centers with the creation of a new nonprofit called Birth Center Equity. This nonprofit was launched in the early weeks of the COVID-19 pandemic to support established and emerging birth centers led by Black, Indigenous, and other people of color, which represent only 5% of birth centers across the USA. In their first eight months alone, the Birth Center Equity nonprofit distributed $100,000 directly to 15 community birth centers through a COVID-19 rapid response fund and went on to distribute another $250,000 to 25 community birth centers to support their operations.

In order to help freestanding birth centers reach their potential, we can:

Take action against requirements hampering new birth centers, such as the Certificate of Need.

In Kentucky (the birthplace of Evidence Based Birth®), there are zero freestanding birth centers due to the Certificate of Need process. The last midwife who attempted to open a freestanding birth center in Kentucky (in 2013) was blocked by nearby hospitals, who argued during the Certificate of Need court hearings that, “We don’t need a birth center, because we have hospitals.”

The Kentucky Birth Coalition, a grassroots movement led by parents, doulas, and midwives, successfully lobbied for the legalization of home birth midwives in 2019, and now they are focused on lobbying Kentucky legislators to provide birth centers with an exemption from the Certificate of Need. But the Kentucky Hospital Association, a powerful lobbying group with deep pockets (more than $17 million in assets and the second-highest lobbying budget in the state), continues to oppose and block bipartisan birth center legislation from passing. To see three separate letters that the KHA wrote to Kentucky legislators in 2023 opposing the legislation that families are fighting for, click here. (create a bit.ly link: ) To donate towards the Kentucky Birth Coalition’s fight to make it a possibility for midwives to practice in birth centers, click here.

Support birth centers as safe alternatives for communities who may face racism in hospitals.

In April 2020, 26-year-old Amber Rose Isaac died giving birth to her son Elias by emergency Cesarean at Montefiore Medical Center in the Bronx, New York City, just four days after tweeting that she planned to write a “tell all” about “incompetent doctors” she experienced through pregnancy. Her story was featured in the award-winning documentary on the U.S. Black Maternal health crisis, Aftershock, now streaming on Hulu, alongside the stories of Shamony Gibson and others who died in childbirth (in some cases, opening up lawsuits of medical neglect). Isaac’s longtime partner, Bruce McIntyre III, is now raising Elias as a single father and has established the saveArose Foundation and joined with Vice President Kamala Harris and other members of Congress to advocate for the rights of Black, Brown and Indigenous women.

McIntyre also joined forces with an existing collective of local birth workers including Myla Flores (doula), Carla Willliams (OB/GYN), Claribel Marmol (CNM), and Nubia Earth Martin (MS in Midwifery) among other changemakers in bringing a freestanding, collaborative care, midwifery birth center to the Bronx!

In December 2021, legislation was passed allowing midwifery-led birth centers in New York, but there have been delays in developing regulations for licensure. As an innovative solution, the Birthing Place BX created the one-of-a-kind Womb Bus – a beautifully decorated minibus and mobile wellness hub that travels the Bronx every week and offers a suite of education and wellness  programming. Residents may engage with Womb Bus at local parks, block parties, and community baby showers. The bus provides preconception education, reproductive counseling, nutrition and mental health support, and supplementary bodywork modalities. They have served over 800 families since their launch in Summer of 2022. If they meet their fundraising goals, The Birthing Place BX can break ground towards the new birth center in late Autumn of 2023. You can donate here.

Support obstetricians working alongside midwives in opening birth centers.

The differences in years of training, credentials, and scope of practice can create major divides across birth workers in ways that didn’t exist prior to health care licensing, when traditional midwives were accountable to their communities, but not to state boards or specific professions. There are benefits to creating different types of professions, but also drawbacks in that we don’t always understand or appreciate one another’s work, and we may even be pitted against each other in fights for funding, medical liability, or the right to exist and practice legally. In contrast, the Birth Center of New Jersey shows us what inter-professional healing and collaboration could look like!

As Medical Director of the Birth Center of New Jersey, Dr. Nicola Pemberton is one of very few Black obstetricians on a freestanding birth center team across the U.S. Dr. Pemberton hosts the “Wellness Collective” as a care collaboration between midwives at the birth center and obstetricians at Artemis OB/GYN, with the option of seamless transfer to Overlook Medical Center without changing providers or interrupting the safety of one-on-one respectful care, and as much as possible, maintaining the intimate feeling of a home birth. The birth center midwifery team includes both Nurse-Midwives and Certified Professional Midwives, and a diverse team of doulas are available to patients as well.

We also want to also uplift Dr. Joia Crear Perry, Dr. Andrea Budreaux, Dr. Kia Lannaman, Dr. Brad Bootstaylor, Dr. Aneke Onwuyani, the Association of Black Cardiologists and the We Are the Faces of Black Maternal Health public campaign. These Black doctors and medical professionals are known for their openness to collaboration, support for birth and reproductive justice, and interest in patient-centered care. We recommend one excellent book to share with doctors in your area to start conversations about birth justice and inter-professional collaboration, titled Shared Decision Making: Bring Birth Back Into The Hands Of Mothers, written by Dr. Bootstaylor in Atlanta, Georgia. You can also listen to Dr. Bootstaylor talk about his book on Episode #84 of the Happy Homebirth Podcast.

Help create birthing centers that reclaim ancestral and cultural ways of birthing.

In 2013, Okunsola M. Amadou visited Elmina, Ghana, “the place of no return” and received a vision of returning home to the U.S. to become a midwife and build a birthing village in the tradition of her ancestors. She founded Jamaa Birth Village in Ferguson, Missouri, to offer midwifery care, doula training, community baby showers and holistic health services, and in 2019, became Missouri’s first Black Certified Professional Midwife! (Listen to more of her story in EBB Podcast Episode #148).

As a team, Jamaa Birth Village has raised over $500,000 in a capital campaign to expand their current model of care from a traditional, Midwifery-Doula care practice to a birthing and postpartum retreat center model. You can donate here to help them reach their goal of $1 million! This new birthing & wellness complex will offer a built-in support system for low-risk birthing people to give birth, rest and heal in a safe and nourishing space, under the care of experts in their community who look like them.

This revolutionary model is similar to the trend of “maternity waiting homes” across Africa, where individuals in rural areas are encouraged to travel early and stay in special lodging near the hospital or birth center, because travel delays are a major cause of maternal deaths in many countries (Lori, Perosky, Munro-Kramer et al., 2019). For the community that Jamaa Birth Village serves, birthing people may not have a support system at home, and so this American model focuses more on postpartum care and community. Unlike in Africa, this is a common missing piece for Black families in the U.S., given the impact of lost culture and separated families due to slavery and mass incarceration, and the eradication of Grand Midwives and cultural midwifery traditions.

Support birth centers in the South and rural areas with high maternal mortality.

As recently as 2017, community-based midwifery care was outlawed in the state of Alabama and practicing non-nurse midwives at any level of training could be imprisoned for attending births. With the decriminalization of community midwives in 2017, there are now new midwife students and plans for a new birth center in Gainesville, Alabama called the Birth Sanctuary, run by Dr. Stephanie Mitchell, the state’s first Black certified professional midwife. You can learn more about Dr. Mitchell’s story of opening the Birth Sanctuary on EBB Podcast #181: Restoring Black-led Nurse Midwifery Care in Alabama.

Another new birth center led by an OB-GYN, Dr. Yashica Robinson, called the Alabama Birth Center, is also poised to open soon. These two birth centers will be among only around a dozen Black-owned birth centers currently operating in the U.S. However, even with these two new birth centers, this still leaves six remaining public health districts across the state without access to midwifery care in a birth center. Many expectant families, especially in rural Alabama, even lack access to prenatal care.

Support Black-led collaboratives of birth workers across your home state:

In Louisiana, another state with some of the poorest birth outcomes, several powerhouse birth workers and organizations are working to change the next generation of birth work! In Opelousas, Louisiana, the Community Birth Companion program is collaboratively nurtured by Midwife Apprentice Divine Bailey-Nicholas and Midwife Ms. Charlotte Shilo-Goudeau of Pick Your Own Birthing Experience. Community Birth Companion provides childbirth education, breastfeeding and herbal support, homebirth midwifery, doula support in all birth settings, and training for birth workers. Ms. Divine is also well-loved for her online ethnobotany course, Grandma’s Hands: Pregnancy and Postpartum Herbs & Nutrition in the Southern Tradition where she passes down herbal wisdom to birth workers across the globe. In Lafayette, Midwife Shatamia Webb just opened the first Black-owned freestanding birth center in the state in 2021! Louisiana is also home to the Birthmark Doula Collective, and to Midwife and Doula Trainer Nicole Deggins, who hosts the largest online directory of Black doulas and midwives.

#2: Community-Based Doulas

What is the difference between a traditional doula and a community-based doula? Community-based doulas are known, trusted, and skilled individuals (often from the same underserved communities as their clients) who are trained to bridge language and cultural barriers and provide culturally grounded, full-spectrum and intensive support that extends through pregnancy, postpartum and often beyond (Health Connect One).

These special doulas hold important roles as patient advocates who offer emotional and informational support to prepare, protect, and hold space for birthing people who are more likely to experience interpersonal and systemic racism through their birthing process (Bey et al. 2019). Community-based doulas often develop a close relationship with their clients, and so can more effectively screen for depression, food insecurity, intimate partner violence, and medical risk factors, connect them with additional support and care, and continue offering wrap around care for months, even years, later. To learn more about how community-based doulas differ from traditional doulas, see Table 2 below.

We remember and honor the life and legacy of Loretha Weisinger, considered by many to be the mother and founder of the community-based doula model. In 2018, Weisinger received the Dick Durban Community Health Worker of the Year Award for over 25 years of supporting teen mothers through childbirth as a doula on the west side of Chicago – the same neighborhood where she once struggled as a teen mom herself. Weisinger’s inspirational story is featured in the award-winning documentary “A Doula’s Story,” and she is known for teaching on how you must nurture the mother, to help her learn to nurture the baby:

“Some of the girls do come here, and they haven’t been parented in a nurturing way. Unless you feel that feeling, you don’t know how to pass it on. And, I tell them, ‘Is it okay if I give you a hug?’ And they’ll tell me ‘Yeah,’ and then I’ll give them a hug. And then I’ll say, ‘Now you see how that felt? I’m hugging you, not trying to get anything from you. Nothing but a feeling. Nothing but to take you where I am.’”

Weisinger initially trained as a doula in 1995 with Health Connect One, a national leader in community-based doula trainings, research, and advocacy. The Health Connect One Community-Based Doula Program is an evidence based and trauma-informed model that has been replicated in over 100 communities across 27 U.S. states, from Detroit to Spartanburg, South Carolina.

A large body of research shows that doulas are a cost-effective model for increasing breastfeeding rates, decreasing Cesarean section rates, and improving birth outcomes and overall quality of care. You can learn more about the research in our EBB Signature Article on the Evidence on Doulas and accompanying podcasts.

In terms of equity, doulas have been shown to lower Cesarean and preterm birth rates for Black and Latine clients, and they can have a “buffering” effect against racism in health care settings (Bohren et al. 2017, Kozhimannil et al. 2016, Thomas et al. 2017). Irth App data show much better experiences from Black and Brown families who had doulas at their births, and many reviews state about certain hospitals, “If you’re going to go here, make sure you have a doula” or “Don’t birth here without a doula” (EBB Podcast Episode #220).

A 2013 study from Minnesota showed lower Cesarean and preterm birth rates among Medicaid recipients who received prenatal education and childbirth support from trained doulas (Kozhimannil et al. 2013). Shortly afterward, Minnesota and Oregon became the first two U.S. states to accept Medicaid reimbursement for doula care—a trend that is quickly spreading nationwide!

Doulas also provide invaluable support through the postpartum period, a vulnerable time when a large percentage of maternal and perinatal deaths occur. In the U.S., there is often a gap in medical care over these first 6 weeks after birth, during which a doula’s attention and care can be lifesaving.

Although there is abundant research supporting doulas, a 2020 California report found that doulas are only present at 6% of births, and they may not be easy to find or pay for in areas where racial disparities are high (Chen and Robles-Fradet, 2020).

To support doulas in reaching their potential, we can take steps to:

Support and refer clients to innovative doula programs and community leaders serving high need areas in innovative ways.

Join or create a local coalition (including Black and Brown birth workers in leadership) to support Medicaid funding and legislation for existing programs. 

The New York Coalition for Doula Access, a group of doulas, community-based doula administrators, health department staff, and others played a role in securing city and state funding for this program, as well as addressing barriers that doulas face when providing care in hospitals. Advocacy groups around the country continue to press for third party reimbursement and hope for national Medicaid coverage for doulas in the future.

Another important part of this work is making sure that the doulas who need it most can access reimbursement. Differing models of doula reimbursement in Oregon, Minnesota, California, and Rhode Island offer helpful insight into what to try, and what to avoid, in new states taking up reimbursement. The Institute for Medicaid Innovation and Every Mother Counts are leading a Learning Series on community-based doulas in Medicaid. Certain birth worker advocates have shared their support for co-op models like in Rhode Island, and their frustration with state-run registries and single agencies being tasked with billing and coordinating all doula payments for the state.

Here are three equity areas we encourage advocates and coalitions to consider in their strategy:

1. Does the nature of the work of community-based doulas require state regulation and certification/licensure, in the same way that medical professionals are regulated and licensed to protect patient safety? Can doulas be effectively regulated by their community or reputation rather than by the state? Can we trust birthing individuals to choose the “right” doula without state or hospital approval? Will a certification or licensure process help narrow their choices in appropriate ways, or will it restrict access?
2. Are there alternative ways to fund doulas that center the birthing individual’s choices (rather than third party criteria) such as a Medicaid prenatal waiver or fund that clients can use toward any doula or birth healer of their choice, regardless of their certification status?
3. How can we uplift community-based organizations as frontline institutions in this work, who train and mentor doulas, and who could create their own forms of “community credentialing” based on their own values? How do we make sure that state doula funding doesn’t pull funds away from smaller organizations and negatively impact the families and doulas they serve?

Allow for flexibility in doula care that can be tailored to different cultural lenses on “support.”

The most common way that doula care is structured and covered under health insurance billing programs is two prenatal visits, attendance at the birth, and one postpartum visit, all assumed to be in-person.

This model was developed by white, middle-to-upper class doulas and families before the COVID-19 pandemic, and may not fit as well for community-based doulas and their clients, or for the ways that health care and communication has become more virtual since 2020.

Some birthing people prefer to text with their doula as needed, rather than set up formal prenatal appointments, or may call for support after the birth, rather than during labor. Clients may lose touch with their doula through the fog of the first weeks with a new baby, but then reach out at a month postpartum, or as they are returning to work, to ask for support or resources.

Coalitions that are advocating for doula reimbursement can create flexible structures to allow doulas to be supportive to (and equitably paid for) birthing people who are juggling multiple jobs with limited time, who have extended family support for the birth but not for postpartum healing, and who may want to connect with a doula virtually or over text or phone, but don’t feel comfortable with full appointments or inviting them into their home.

Support and mentor a doula of color.

Because of their role as patient advocates and “buffers” against microaggressions and unequal care experienced by their clients, community-based doulas can experience secondary trauma – on top of working long hours for low pay, if any pay. They are at a higher risk of emotional challenges, burning out, and leaving community-based work, even though their work is lifesaving.

You can make a difference by reaching out to a community doula to offer them a free meal after a hard birth, or donate $25/year to buy them a membership to the Black Women’s Birthing Justice (BWBJ) Black Birthworker Forum. This is a monthly virtual space for new and experienced Black birth workers (including doulas, midwives, lactation professionals and more!) to share strategies to support clients and feel supported in their own self-care and work-life balance. The Forum is lead and guided by the needs of the forum participants and facilitated by BWBJ co-founder Mama Linda Jones and licensed clinical psychologist and doula, Dr. Sayida Peprah-Wilson.

Dr. Peprah-Wilson (@drsayida) is a consultant and public speaker on birth justice, implicit bias, and mental health topics. Dr. Peprah-Wilson gives voice to the importance of self-care, community, and mental health support – both for birthing people experiencing racism and for doulas experiencing racism directly and vicariously, along with their clients.  She is also the founder and executive director of the nonprofit Diversity Uplifts, Inc. which provides equity and trauma-informed training to perinatal professionals and supports BIPOC-led community doula programs in Northern and Southern California including the Frontline Doulas (Los Angeles), Sankofa Birthworkers Collective (Inland Empire), Black Women Birthing Justice Community Doulas (Oakland community) and the Roots of Labor Birthworkers Collective (Bay Area).  Each of these programs trains, funds, and provides no-cost BIPOC doulas to BIPOC families.

A new Irth® Ambassador program in New York City is also bringing together 25 doulas and birth workers to support them with mentorship and opportunities to increase their income. Events include a speaker’s series and coaching around mental health, business building, sustainability, self-care, fun and joy! In the words of Kimberly Seals Allers, it should not be “this lionization of doulas without us loving on them, without us putting back into their cups as well.”

Expand sustainability of the doula profession through employee benefit models.

Many community-based doulas end up taking on birth work as a side job or volunteer activity, because it generally is high intensity work with low pay (if paid at all), and without the option of paid time off, guaranteed back up, or any other benefits.

In San Francisco, California, SisterWeb is a doula collective offering Black, Native Hawaiian, Pacific Islander, and Latina/o/x doulas the option to be hired as employees and be paid a competitive hourly wage, with benefits for those working over 25 hours per week. Billable hours include time spent in meetings, trainings, and mentoring sessions with experienced doulas and midwives. Doulas connect with clients of the same cultural background in cohorts, where each birthing person is supported by a team of 2 to 3 doulas, all services free of charge. Per their website, in 2021, SisterWeb doulas received 212 sessions with their mentors, attended 86 births, made 539 prenatal and postpartum visits (up to 7 visits per client), spent an average of 16.7 hours of on-call support for labor and delivery per client, and provided 30 hours of direct care with clients on average, through the perinatal period.

Ravae Sinclair, former President of DONA International, is also now working on a perinatal association called International Perinatal Professionals, that would help offer similar benefits, structure, and support to the profession, without adding barriers to entry.

#3: Reparations and Transformative Justice

Who holds care providers accountable after they commit microaggressions or obstetric violence? And who holds health care institutions (including educational institutions that train health care workers) accountable for the harms of structural or systemic racism?

Those of us who are health care workers might not even be aware of when racism or cultural appropriation show up (even unintentionally) in our own practice, or when we cause harm to our clients or patients. Are we asking for client feedback that elicits harm from racism? And when clients take the risk to give feedback that they’ve been harmed by racist practices, do we take it to heart and make changes? Or do we act defensively and eventually put our heads back in the sand?

In health care and birth work, how are we developing new cultural practices that repair harm, rather than perpetuate it, ignore it, litigate it, or criminalize it?

As advocates, we may be aware of how easy it is to engage in “Cancel Culture” and the power of using our voices to name harm and injustice on social media, but does that bring us to healing? What could “Repair Culture” look like in birth work?

There are a few individuals making bold steps in this direction, including parents who are pursuing truth through hospital lawsuits, the team behind the Irth App, and individuals sharing stories on social media. But we didn’t choose reparations and transformative justice as the third piece of the Equity Triad because of the abundant information and research in this area of birth justice – actually, we chose it because there’s NOT.

In the field of global maternal health, a growing research area is dedicated to uncovering the best ways of holding hospitals accountable to reducing perinatal deaths and ending disrespect and abuse toward patients in childbirth. A 2016 review by Hilber, Blake, Bohle et al. evaluated 38 papers over a six-year period and found three major categories that accountability measures fall into:

1. Performance Accountability
2. Political / Democratic Accountability
3. Financial Accountability

Performance Accountability includes measuring and evaluating hospital performance and improving service delivery, for example through perinatal reviews, changing professional norms, standards and committees, and carrying out monitoring and evaluation projects.

Political or Democratic Accountability speaks to social accountability methods, such as social audits or public complaints, petitions, campaigns and protests, community “scorecards” and public debates highlighting perinatal deaths and mistreatment in birth as human rights violations.

Financial Accountability describes hospitals’ compliance with laws, rules and regulations and includes approaches like performance-based financing. Hilber et al. conclude that the most effective accountability methods so far have reinforced rules, regulations, or practice norms with a threat of punishment and public awareness, through social and political advocacy.

In the U.S., however, there’s a stark silence in research and equity conversations around how to effectively hold care providers, hospitals, and professional associations accountable for the harm they cause. Associations like the American College of Obstetricians and Gynecologists (ACOG), and American Medical Association (AMA) have caused harm over generations by attempting to criminalize and eradicate Black and Brown midwives from the U.S., and making it nearly impossible for many years for Black and Brown students to enter medical school or residency. We have not seen any consequences nor robust public awareness of this harm and its continued effect on our health care workforce diversity.

Furthermore, the American College of Nurse Midwives played a role in preventing community-based midwives (many of whom were Black and Brown midwives) from practicing, by lobbying against state legislation that would legalize certified professional midwives – an effort that stopped only in 2015 with the signing of the U.S. MERA agreement.

From the evidence-based accountability framework above, we can see how awareness alone will not change circumstances in birthing rooms across the U.S. Instead, performance or financial consequences are needed, and many advocates would add that reparations are due.

High profile cases of Black maternal deaths like Kira Johnson, Amber Rose Isaac, and Shalon Irving continue to be reported. Stories of disrespect and obstetric violence fill the entries of the Irth App. Individuals continue to live with traumatic memories and the ripple effects on their health, their children, partners, and families.

The global protests during the summer of 2020 opened the door to racial healing in ways that had never existed before in mainstream American culture. Senator Cory Booker and Representative Barbara Lee introduced federal legislation to create a Truth, Racial Healing, and Transformation Commission, that continues to need co-sponsors and public support if it’s ever going to advance.

In contrast to Germany, which paid reparations for the Holocaust, and Canada, which paid reparations to Indigenous communities to make amends for placing their children unnecessarily in foster and child welfare systems… the U.S. has never paid reparations for slavery or the continued injustice and torture of Black communities during the Jim Crow era. Many nations have called out the U.S. for our hypocrisy, noting that bills calling for reparations from slavery have stalled in Congress for decades.

We would like to propose these issues be brought to the forefront in discussion of birth equity:

• A longitudinal study in 2010 by Alcorn, Donovan, Patrick et al. surveyed over 900 women and found that up over 45% reported experiencing “birth trauma.” Advocate and former Public Affairs Communications Strategist Cristen Pascucci of Birth Monopoly provides step-by-step resources for individuals who are interested in filing a formal complaint or appeal, but she also urges survivors of birth trauma to keep in mind what is their goal behind filing a complaint. In EBB Podcast Episode #170, Pascucci recommends asking: “Can I only heal if I get recourse, if I get validation from this other party that I was wronged? Or can I take this on myself and use it to tell my story, and own my story, and heal around my story?

Healing from birth trauma and concepts like healing justice have become popular, but there is little research or consensus around how exactly this healing happens, and if healing methods may differ across different cultural groups. Many doulas are trained to write down the birth story and hold a postpartum visit with the birthing person to retell and remember the birth story, which research shows can help with recovery and coping after trauma (Tuval-Mashiach, Freedman, Bargai et al., 2004). Through oral culture and social media, birth workers continue to discuss, explore, and share about approaches such as “rebirthing” sessions, body-based therapies, cleansing/releasing, and grief/rage rituals that they offer clients in the aftermath of birth trauma.

• Chanel Porchia-Albert of Ancient Song Doula Services has brought Decolonize Birth conferences to the front steps of a local hospital, asking for conversation and amends for cases of obstetric violence. Just Birth Space is taking an active role in accountability conversations with hospitals in New York City. But as Cristen Pascucci detailed in her EBB podcast interview about hospital complaints, filing a complaint with a hospital does little to change hospital policy or practices. It can be compared to asking a restaurant to hold itself accountable for a case of food poisoning—there is no incentive for the restaurant to publicly apologize for its missteps.

Currently, there is no hospital accountability for episodes of racism or unsafe maternity care. If we can’t immediately change hospital culture, or federal policy, at the very least we can ask hospital administrators to learn more about transformative justice and how it could be applied to medical and obstetric harm that has occurred in their facilities.

• The American Medical Association (AMA) and American Congress of Obstetricians and Gynecologists (ACOG) contributed to the elimination of Southern Black Grand Midwives, lobbied for changes in the medical system that closed down medical schools accepting women and future doctors of color, and opposed the introduction of Medicaid which de-segregated hospitals. All these actions are grounds for discussing reparations, or at least beginning a process of making amends. What if the AMA and ACOG, who have enormous budgets funded by upper class physicians, be held responsible for helping pay tuition for Black and Brown students to attend midwifery school? See the AMA’s budget surplus here.
• What can reparations look like in a case in which racism led to reproductive harm? Let’s take the example of the Relf sisters. Mary Alice Relf and Minnie Lee Relf, two black sisters aged 12 and 14, were forcibly sterilized in 1973 in Alabama. Their mother, who could not read, was given a paper to sign with an “X,” which she thought was for birth control shots. The young girls were taken to the hospital by two nurses, and their ability to reproduce was surgically removed. Their older sister, Katie Relf, told their parents about the surgeries, then hid in the closet when the nurses came back to get her for sterilization.

Mary Alice Relf and Minnie Lee Relf’s sterilizations were part of a widespread federal effort to stop reproduction among poor people, poor Black people, and disabled people—sterilizing 150,000 people per year at the campaign’s height. A lawsuit filed by the Southern Poverty Law Center in the Relf sisters’ name finally stopped this practice (Relf v. Weinberger), but Mary Alice and Minnie Lee were already rendered permanently sterile and never received a penny in reparations from the state, nor an apology. Although three states have taken steps to pay financial reparations to victims of sterilization campaigns, Alabama is not one of them.

In 2022, Michelle Browder, the artist, entrepreneur, and creator of the Mothers of Gynecology monument in Montgomery, Alabama, created a GoFundMe campaign to help the Relf sisters with living expenses as they continue to await justice. More than $20,000 was raised online. At the 2023 “Anarcha, Lucy, Betsey Day of Reckoning Part 2” conference, Michelle announced to attendees that a white woman had paid an additional $50,000 as reparations for the harms done to the Relf sisters. Michelle and her mother, Buena Browder, helped Mary Alice and Minnie Lee, who are now in their sixties, find and purchase a house with cash, so that they could move out of public housing and finally have a place of their own. An additional $15,000 from the GoFundMe was used to pay off credit card debt and a car payment for Katie Relf.

• One simple method to practice accountability and make amends is called Circle Practice – a process adapted from Indigenous cultures around the globe to guide mediation sessions between a victim and offender (Pranis, 2005). The process involves first asking consent from both sides of the conflict to participate. If both agree, then a meeting (or series of meetings) can be planned during which trusted mediators help facilitate respectful and honest conversation explaining both sides of the story and reviewing the harm and its broader impact across communities. Hearing from one another face-to-face and understanding the harm and its effects can be an emotional, transformative, and perspective-expanding experience. These mediation sessions deeply impact individuals and can cause long-lasting change.
• The “professionalization” of birth and healing work in the U.S. carries a history of cultural appropriation, misuse, or extreme commodification of global Indigenous techniques and tools such as the rebozo, gua sha, burning sage, and Florida water, among others. At EBB, we encourage birth workers of primarily European descent to do research and ask family members to find what cultural birthing traditions were used in their own ancestral line or their countries of origin. For all birth workers, learning about someone else’s culture can be a great way to connect with new colleagues and communities to expand your Soul Family network! You can learn more about how cultural appreciation can be a pathway to self-awareness and healing on EBB Podcast Episode 213: Cultural Appropriation and Racial Healing in Birth Work.

Social movements like Restorative and Transformative Justice arose from prison abolitionists as ways to repair harm and reimagine mutual accountability. Can you imagine how the birth world and health care could change if we hosted real conversations between providers, medical staff and institutions, and birthing people? Open conversations are often considered “impossible” due to liability risk, but the restorative justice movement has found creative ways to succeed that birth workers can take inspiration from.

Since 2004, the Minneapolis Police Department has been diverting certain cases (often juveniles with minor offenses) to organizations like Seward-Longfellow Restorative Justice to host confidential mediation sessions that bypass the legal system entirely.

In birth, could we create something similar? What else could we imagine, over the next generation of birth work, to help transform our birthing experiences from pain into power?

Transformative Justice in Leadership Challenges

Note: When we sent this paper out for external review, we were asked by some of our Black reviewers to add a section on Transformative Justice in Leadership Challenges, which you can read below.

Over the past decade, we have watched as new Black leaders in previously white-led organizations were fired, pushed out, removed, or ignored soon after taking office, in some cases with no transparency and/or no true just cause. In other cases, Black leaders were omitted from the organization’s historical timelines to downplay their achievements, tone policed, not permitted to run for office, or publicly humiliated in front of other members. The list of Black leaders who have expressed that they experienced harm from organizational birth work includes (but is not limited to) Ravae Sinclair, the first Black President of DONA International, Denise Bolds, the second Black President of DONA, Dr. Andrea Boudreaux the first Black CEO of Lamaze International, and Dr. Michelle Drew, CNM, at the American College of Nurse-Midwives.

In her initial acceptance of the position of CEO as Lamaze, Dr. Boudreaux spoke to the importance of going beyond diversity, saying: “Diversity, equity and inclusion is about more than simply hiring minorities. It is about transforming business practices to specifically outreach to underserved communities.” Dr. Boudreaux, like many other Black leaders, openly shared interest in making changes to previously white-led organizations so that they could become more welcoming and supportive to members of color. Dr. Boudreaux shared with us that she was removed for speaking about injustice, and after bringing on an African-American obstetrician consultant (who was approved by the Board before they knew her race) to help Lamaze move into more academic institutions. Ravae Sinclair had spent seven years on the DONA Board as Multicultural Director, and Denise Bolds campaigned on the promise of budget changes to support Black members who had previously not received as much benefit from DONA membership. As the descendant of ten generations of Black midwives, Dr. Michelle Drew works tirelessly to serve Black families in Delaware; at ACNM she served as inaugural chair of the Caucus of Black Midwives for Reproductive Justice and Birth Equity.

Historically white-led organizations may highlight their commitment to “diversity” by electing or hiring Black women and Black people as leaders. However, here at EBB, we believe that until white supremacy culture is rooted out, organizations will continue to cause harm to Black leaders in birth work, to the Black members who watch these crises unfold, and to future leaders of color considering applying or running for positions.

What would transformative justice look like in situations when organizational harm has been done to our own leaders, colleagues, and coworkers? When, due to unexplored racial biases, board members or other committee members consciously or subconsciously view Black women leaders as too loud, too brash, too bold, too “bossy,” too “angry,” or too “disrespectful”?

Unfortunately, racial biases against Black women, tone policing of Black women and Black LGBTQ+ folks, and organizational expectations of “professionalism” are rooted in a long history of seeing white ways of doing things (such as how we carry out meetings… see Part 1: Soul Family & Solidarity) as the superior way. It will take Circle work, transformative justice, and a willingness of white colleagues to be humble and admit wrongs for us to begin to repair relationships so that we can work together to tackle the real enemy—the racism that is leading to a maternal and infant mortality crisis in the U.S.

In the meantime, it should come as no surprise that rather than attempting to assimilate into professional/white cultures that don’t truly want them, Black, Brown, and Indigenous birth workers will continue to create and support their own associations and organizations.

Additional Equity Tools

In addition to the Equity Triad, we’d like to mention a few additional “equity tools” that are not as essential as those listed earlier, but still important for allies to understand:

• Implicit Bias Training
• Research
• Public Policy
• Intersectional Frameworks

From implicit bias trainings to the Momnibus Congressional legislation, all these tools can be used to raise funds, shift public health policy, and amplify the Equity Triad. These additional tools may be secondary, but they are critical in the way they have opened doors to resources, new ways of thinking, and strategically utilized some of the tenets of white supremacy (worship of the written word, for example) to carry forward anti-racism efforts into broader communities.

Training as an Equity Tool

Implicit bias training is a commonly proposed solution to racism in health care and birth work, and new state laws, enacted first in California (followed by several other states), now require continuing education hours in equity training for perinatal health care providers.

An excellent training that we highly recommend is called the “Dignity in Pregnancy Childbirth Project” designed by Dr. Rachel Hardeman and her team at the University of Minnesota Center for Antiracism Research for Health Equity (CARHE, pronounced “care”) in partnership with Diversity Science. It is freely available online and takes about one hour to complete. Alongside learning history and evidence-based anti-racism strategies, it takes you through a sample case review of a woman who died in childbirth (based on true stories) and allows you to “freeze frame” the story to better understand how communication breakdowns interrupted her care.

Dr. Sayida Peprah-Wilson also provides in-person and online implicit bias trainings, workshops, and self-reflective exercises, throughout the U.S.  You can find a list of upcoming trainingsand activities via her social media @drsayida and websites DrSayidaUplifts.com and DiversityUplifts.org/Learn.

Research also shows that trainings tend to have a limited, short-term impact, whereas cross-race empathy and community building strategies have the possibility of more sustained change (Pritlove, Juando-Prats, Ala-Leppilampi et al., 2019).

• In 2011, Italian researchers performed a series of experiments to better understand how we perceive other people’s pain (Forgiarini, Gallucci and Maravita, 2011). Participants were asked to watch a video of a needle piecing another person’s skin, and researchers tracked their reactions by measuring the amount of stimulation found in the pain perception areas of their brain. The authors found that when white people watched other white people in pain, their brain was activated as if they also felt pain–a surprisingly visceral form of empathy. This reaction was muted, however, when they watched someone of a different race. Our takeaway from this is that we deeply feel other’s pain, but we don’t feel everyone’s pain in the same way. We feel more pain and more empathy, for people we identify with, and less pain and less empathy, for those we see as strangers.
• This cross-race empathy gap dropped by 55% when providers were asked to take a moment to put themselves in their patient’s shoes (an approach supported by research called “perspective-taking”). Perspective taking can also look like using language like “we” and “us” to remind everyone that we are on the same team and share common goals. (Drwecki, Moore, Ward et al., 2011)
• In 2020, researchers at the University of Washington in Seattle conducted a randomized control trial with medical students and recent graduates to test the effectiveness of different types of anti-racism and implicit bias training (Kanter, Rosen, Manbeck et al., 2020). They found that an innovative clinical workshop design with three key elements had the most success in reducing racial microaggressions and increasing their emotional connection and responsiveness toward patients of color.

The three key elements included:

1. Classroom instruction on health inequities, stereotypes, microaggressions, interracial provider-patient interactions, and racism.
2. A guided, interracial eye-contact mindfulness exercise, designed to increase providers’ awareness and mindful acceptance of the subtle ways that bias often occurs in cross-race interactions.
3. Small group exercises where participants practiced their eye-contact and mindfulness skills in cross-race conversations, including sharing and responding with empathy to one another’s personal stories of loss and/or betrayal. In other words, this was a skill building exercise in offering and receiving empathy across race in moments of vulnerability.

A 2022 study showed that interracial contact alone may not reduce racism, such as having one Black friend or working with multiracial colleagues at the same hospital (Brown, Culver, Bento et al., 2022). The authors speculated that “whites dating outside their race may believe their relationship proves racism is a thing of the past” and so may express more racial apathy.

Instead, evidence points to effective trainings and workshops that include a carefully facilitated combination–education on the ongoing racial disparities and tragedies, mindful self-reflection, spaces for building authentic interracial community and empathy, and using words like “we” and “us” to see ourselves as having shared goals and shared humanity through challenges.

Research as an Equity Tool

The term “Research Justice” was first described by Oakland-based grassroots organization Data Center. Research Justice is a framework for seeing research (when done equitably) as a key part of systemic change for Black people, Indigenous people, people of color, and people experiencing oppression in all forms (Jolivette, 2015). This includes community-led, participatory research methods that keep data accessible and accountable to the people being studied—where they can guide the questions and use results in helpful ways for their own lives.

As shared by doula and public health professional Xian Brooks on EBB Podcast #227, white principal investigators are almost twice as likely to get funding than researchers of color; and only 35% of grants are awarded to people who identify as women, with 4 in 5 of the “gold standard” R01 grants going to men (Taffe and Gilpin, 2021). Still, powerhouse Black and BIPOC researchers and academics are out there! They are applying and advocating for the scientific rigor of research to be used in identifying solutions to racism and racial health inequities.

• Karen Scott, Associate Professor and OBGYN Hospitalist at the University of California, San Francisco, and Founder and CEO of Birthing Cultural Rigor, LLC, led the SACRED Birth Study to create a first-of-its-kind tool to define and measure obstetric racism. The “PREM-OB Scale” was designed through a process that centered the lived experiences of Black birthing people, and the language and ways that they have experienced obstetric racism and harm in their birthing journeys. This scale, that can be used to assess and respond to racism in the future, was created by and for Black birthing people, community, and content experts.
• Rachel Hardeman is a tenured Associate Professor and the Blue Cross Endowed Professor in Health and Racial Equity at the University School of Public Health and Director of the Center for Antiracism Research for Health Equity (CARHE, pronounced “care”). Dr. Hardeman is conducting a five-year study on the impact of neighborhood police violence on birth outcomes for Black infants, including preterm birth. As part of a partnership with Roots Community Birth Center, Dr. Hardeman’s past research has been used to support Medicaid insurance coverage for doulas in Minnesota and nationally. Her studies were among the first nationwide to show that doula-attended births had lower Cesarean and preterm birth rates and potential for significant Medicaid cost-savings (Kozhimannil, K., Hardeman, R., Attanasio, L. et al., 2013). Dr. Hardeman’s groundbreaking research also includes developing frameworks for identifying racism in Maternal Mortality Review Committees (Hardeman, Kheyfets, Mantha et al., 2022), measuring structural racism (Hardeman, Homan, Chantarat et al., 2022), and advocating for public health researchers to name and acknowledge the impact of structural racism in their studies (Hardeman, Murphy, Karbeah et al., 2018).
• At EBB, we value evidence and knowledge in all its forms. Evidence often includes peer-reviewed journal articles, systematic reviews, and meta-analyses. However, we also recognize that the field of research itself perpetuates inequalities that are already embedded in our societies. Academic research, published books, and large media outlets are more likely to express the perspectives of male, white, cisgender, wealthy populations, English-speaking and Western countries, and health professionals formally educated in science and the biomedical model. This doesn’t represent the global majority or the only perspective on birthing. We work to educate ourselves and others to avoid being “health equity tourists”. We commit to uplifting the work and words of Black, Indigenous, people of color, LGBTQIA+, and women researchers, and to include traditional knowledge and wisdom even when it may not have made it into a peer-reviewed journal or published book. We look for creative ways to include and cite Grand Midwives, community healers, and others whose perspectives are important to document for all of us.

Public Policy as an Equity Tool

Racial health inequities and the Black maternal health crisis have been elevated lately, with the support of public resources like the Black Mamas Matter Alliance Toolkits  and the 2020 U.S. Civil Rights Briefing to Congress, which included testimonies on racial disparities in maternal and perinatal health.

• Across the U.S., Maternal Mortality Review Committees (MMRCs) are multidisciplinary statewide teams that gather regularly to discuss the cases of people who died within one year of being pregnant. Local representatives are invited from a variety of fields to guide a comprehensive review of the immediate and root causes of the death, including medical concerns, socio-cultural conditions that may have contributed to disease and death, and if the death could have been prevented. Members represent public health, obstetrics and gynecology, maternal-fetal medicine, and specialty areas such as cardiology, nursing, midwifery, forensic pathology, mental and behavioral health, patient advocacy, and community-based organizations.

Data and recommendations from each MMRC are collected by the Centers for Disease Control and released in periodic briefs to provide a nationwide picture of the state of maternal mortality, as well as insights on how to prevent future deaths. These review committees have been the major focus of a national strategy to monitor and respond to maternal deaths, in a similar way that other medical concerns or infections and epidemiological crises have typically been monitored (surveillance systems like these alert us to rises in COVID-19 cases, for example).

The challenge of these review committees is that they are focused on developing solutions from a framework of analyzing the causes of death. For complex health issues like maternal mortality, it can be challenging to discern the impact of structural racism or poverty versus something like cardiac output or blood loss on a particular case (and with limited information available). Researchers such as Dr. Rachel Hardeman, of the the Center for Antiracism Research for Health Equity (CARHE, pronounced “care”), and Dr. Joia Crear Perry, of the National Birth Equity Collaborative, have released tools and conceptual models for MMRC members to follow in order to accurately capture the impact of racism on perinatal deaths (Hardeman, Kheyfets, Mantha et al., 2022).

• In 2016, the American College of Obstetrics and Gynecology created an Alliance for Innovation on Maternal Health (AIM) bundle. This includes nationwide hospital recommendations to reduce racial and ethnic disparities. Other AIM bundles had already been created for improving patient safety and care protocols for obstetric hemorrhage and severe hypertension, among other topics. The Peripartum Racial/Ethnic Disparities bundle recommends that health care systems:
• Educate all staff in implicit bias, the root causes of peripartum racial and ethnic disparities, and shared decision-making.
• Make efforts to engage patient, family, and community advocates as community partners on quality and safety leadership teams.
• Develop mechanisms to report cases of unequal care, miscommunication, or disrespect, and respond with a timely and tailored response.
• Improve patient communication and education around warning signs to watch for after discharge.
• Track race and ethnicity among outcomes and within internal reviews, including process and outcome metrics.
• In April 2022, the American Rescue Plan Act of 2021 gave states a new option-to extend Medicaid coverage after giving birth for up to 12 months (although without federal matching funds, and the option expires after 5 years). Supported by expert researchers and advocates including Monica McLemore, Karen Scott, and Jamila Taylor, this change can help close the postpartum gap in care in 34 states and counting. Before this change, if a person who is uninsured got pregnant, they could apply for Medicaid to support them through a healthy pregnancy with affordable prenatal care, but after 60 days postpartum that coverage would end.

To put this in context, Cesarean sections generally take 8-12 weeks to fully heal (up to 84 days). Medicaid covers almost half (43.1%) of births in the U.S. and, in some states, families are eligible to extend affordable insurance coverage through state programs; but in many states, they simply lose insurance. Most (60%) of maternal deaths occur in the postpartum period, a majority of which are considered preventable (McLemore, 2019). Research also shows that closing this gap in coverage can support families in breastfeeding/chestfeeding as well as emotionally as the family transitions into supporting the new baby (The Century Foundation, 2020). But we still need more states to adopt this Medicaid extension!

For more information and to see which states have made this change, please visit the Postpartum Coverage Tracker Map.

• One national bill still pending is the Black Maternal Health Momnibus bill, which is currently (at the time of writing in October 2022) under consideration in the U.S. Congress. An “omnibus” bill is a piece of legislation that combines several different subjects into one, and the aptly named “Momnibus” combines 12 unique pieces of legislation. As a united package, the Momnibus would fund support programs for maternal mental health and pregnant and postpartum veterans; improve data collection on maternal health; and offer protection for families from the risks of COVID-19, climate change, and more. The Momnibus was reintroduced in 2021 by Congresswomen Lauren Underwood (D-IL) and Alma Adams (D-NC), Senator Cory Booker (D-NJ), and additional members of the Black Maternal Health Caucus.The package is endorsed by over 240 organizations (listed here) who describe their support in quotes (here).

A California Momnibus bill passed in 2021, giving a glimpse into what the nation could expect if the national version also passed. SB 65 was introduced by Senator Nancy Skinner and passed with the support and collaboration of local organizations including the Black Women for Wellness Action Project, California Nurse Midwife Association, and March of Dimes. The law strengthens the work of the Pregnancy Associated Mortality Review Committee to investigate and prevent deaths, improves data tracking, supports the expansion of midwives, and introduces Medi-Cal (California’s version of Medicaid) public insurance coverage for doulas. On the day of its signing, California Governor Newsom acknowledged the fight to end structural inequities and racism as a central focus of this bill:

It is unacceptable that the maternal and infant mortality rate among Black and Indigenous communities remains significantly higher than the state average. California is committed to tackling discrimination and disparity whenever and wherever it occurs and with today’s signing, we’re doubling down on our commitment to both reproductive and racial justice.”

– California Governor Gavin Newsom

• Additional public policy areas like abortion care and family paid leave continue to be hotly debated in the U.S. Since the overturning of Roe v. Wade and the constitutional right to abortion, a New York Times analysis showed that the 24 states with current/likely abortion bans offer the least supportive overall programs for mothers and children, and some of the worst health statistics around maternal deaths, teenage birth rates, and uninsured families. Many of these states have turned down the Postpartum Medicaid Extension option, and many declined the Medicaid Expansion option from the Affordable Care Act.

The U.S. is also the only industrialized country without national paid maternity leave. According to NationalPartnership.org, 85% of U.S. workers have NO access to paid family leave. Policies are left up to employers, and may be outdated or insufficient, especially for families of color. Offering the option of family leave may also not be enough, as there are staggering racial disparities around taking perinatal leave. One analysis of the Current Population Survey for 1994 to 2015 showed 69% of white birthing people taking available leave, as compared to 13% of Black and 12% of Latinx birthing people (Zagorsky, 2017).

Intersectional Frameworks as Equity Tools

“Reproductive Justice is the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” –SisterSong

Reproductive Justice is a term coined by a group of Black women in Chicago in 1994, as a call to combine human rights with reproductive rights, and to give voice to women of color, trans women, and other marginalized people in the movement. In 1997, SisterSong formed as a community organization in Atlanta, Georgia to create a multi-ethnic movement supporting the full diversity and rights of people at the margins.

Many other justice movements were forming during this time, such as the term healing justice coined by Cara Page, disability justice raised by Patty Bern, Mia Mingus, and others, and restorative justice or transformative justice as alternatives to incarceration and prisons, supported by abolitionists like Mariame Kaba and adrienne maree brown.

Activists around the U.S. were calling for a shift in leadership and acknowledgement that all people, regardless of money or privilege, deserve dignity, humanity, and human rights.

The reproductive justice movement shows us how all these pieces are needed to keep birthing people safe and to help them raise strong, happy, and healthy children. Many birth workers of color spoke publicly about the fact that George Floyd, just before he died under the knee of Derek Chauvin, called for his mother–-and that this is an example of the need for reproductive justice, so that the babies we birth can grow and live in a world free from all types of violence.

Frameworks like reproductive justice and transformative justice can help us ground in social justice history and theory, as we create new events, programs, design quality improvement efforts, and assess gaps in services.

One way to begin is to ask: Who is not at the table? (And who decided we’re at a table?)

Individuals may not access programs they need simply because they can’t pay for them, or they don’t feel welcome, or they don’t have transportation or childcare, or because they’ve never heard of it. Most of these barriers can be solved, and many programs do specialized outreach and offer childcare, transportation vouchers, or gift cards to help make it easier for people to join them. It is also culturally acceptable in the U.S. to take a business perspective and focus services on a “target market,” or to throw your hands up and say, “Well, of course we can’t serve everyone!” But is that always true?

Public health programs are designed specifically to address everyone, and there are popular models that include program participants in leadership positions, Community Advisory Boards and more (CITE). In the case of a pandemic or infectious disease outbreak, leaving some people out will have a negative effect on the entire community, so it’s in everyone’s interest to involve as many people as possible. The “seat at the table” analogy also assumes a limited number of people, but what if we imagined an amphitheater, or a Zoom room with limitless capacity, or a nature retreat where “power” is associated with land, relaxation, authentic conversation, and connection?

Many traditional cultures hold rituals and celebrations to welcome newborns and young people entering adulthood, because they see the health and belonging of every community member as important to the whole, as explained by West African author and elder Malidoma Some in The Healing Wisdom of Africa:

“The community loves to see all of its members flourish and function at optimum potential. In fact, a community can flourish and survive only when each member flourishes, living in the full potential of her or his purpose. To honor and support its members is in the self-interest of any community.”

A similar concept that embraces the whole, rather than individual parts, is called intersectionality and was coined by U.S. civil rights and feminist lawyer, Kimberlé Crenshaw. Intersectionality helps us understand how race, gender, class, and sexuality (as well as many others!) co-exist, overlap, and intersect with each other-and why that matters in our activism. We are all complex beings, much like a large patch-work quilt of identities, and we deserve to carry all of us with us, wherever we go.

Xian Brooks of Dandy Doula speaks to this beautifully in EBB Podcast Episode #227, saying: “Intersectional birth work basically just means practicing or providing services in a way that people can bring their full selves into their care.”

All of us matter. Our shared history matters. Despite how white supremacy and the medical industrial complex may make us censor parts of ourselves, separate us into “us” vs. “them,” and force us to seek health care in silos with separate buildings and disconnected providers.

We see parents going all in to prepare for labor and birth, meanwhile missing important preparation for postpartum healing and breastfeeding/chestfeeding. We witness passionate advocacy campaigns against “Don’t Say Gay” bills, yet a surprising silence around similar laws against Critical Race Theory (scholars suggest these bills could be renamed “Don’t Say Racism”). We promote gender inclusive language as a symbol of our care for all birthing people in the U.S., yet ignore the plight of women, girls, and non-binary people who are subjected to extreme levels of violence in other parts of the world. We know we cannot possibly advocate in all the different directions – but we can keep our eyes on the intersections, at the center of many oppressions and misunderstandings about each another.

We recognize that many birth workers who identify as cis-gender women may hold blank spots around gender. We can make well-meaning, but false assumptions that birthing people want to be called mothers, or that as birth workers, we all use the same terms of endearment like woman or sisterhood. Iya Mystique Hargrove of Black Birth Healer reminds us that not everyone is your “sis!” The entire field of birth work is elevated by trainings and talks on Intersectional Black Birth from visionaries like Xian Brooks and Iya Mystique, as well as King Yaa, Cheyenne of The Educated Birth, Nadine Ashby of Birth Revolution, the Queer and Transgender Midwives Association, and more. We encourage all birth workers to follow and take trainings with these Black and Brown Birth Visionaries! You can also learn more by listening to the EBB Podcast Episode #182 on Black-Led Queer and Trans Birth Work.

As birth workers and healers, we know that we cannot successfully treat one part of the body without treating the whole. From functional medicine, Indigenous, and integrative approaches to healing, we also understand that it is more effective to treat the root cause of disease, rather than chasing symptoms.

Our activism shouldn’t make us choose between equally important issues and identities. Here at EBB, we try our best to work against “either-or thinking” and gatekeeping (commonly found in white supremacy culture); and instead, teach how to be change makers at the root of many intersections. We witness how the culture of white supremacy leads us to dismiss or see one another as competitors, rather than collaborators–regardless of the -ism at play.

Reproductive justice asks us to be aware of the fullness of the reproductive experience of our clients and patients. If we support someone’s ability to advocate for themselves in labor, but not their ability to access contraception, abortion, or to protest police harassing their children, then we are not seeing their full identity and dignity.