Rebecca Dekker, PhD, RN &
Ihotu Jennifer Ali, MPH
The Evidence on: Anti-Racism in Health Care and Birth Work
A Welcome Note:
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.
Transcript from Podcast Episode
Hi everyone. On today’s podcast, we’re going to talk about the research evidence on equity tools and anti-racism in healthcare and birth work.
Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.
Hi everyone, my name is Rebecca Dekker, pronouns she/her, and I’ll be your co-host for today’s episode. Today along with our co-host Ihotu Ali, we are so excited to bring some brand new evidence-based information to you all about the evidence on equity tools and anti-racism and healthcare in birth work.
Yes. Hello, my name is Ihotu Ali, pronouns she/her, and I’m excited to announce that this March and April of 2023, we published a brand new signature article here at EBB. So the title of that article is The Evidence on Anti-Racism and Healthcare and Birth Work. So in today’s podcast episode, we are celebrating the release of this article by talking about a major section of this article all about equity tools. We talk about an evidence-based equity triad that we found in the research and anti-racism research in general and ways to fine tune and hone your skills as an advocate in this area.
So for those of you who have not yet listened to Ihotu Ali, she’s been featured on multiple podcasts here at Evidence Based Birth® over the past few years. Ihotu is EBB’s research editor as well as founder of the Oshun Center for for Intercultural Healing, which is an integrative healing clinic and community center for ancestral and cross-cultural learning. And as clinic director there, Ihotu practices and teaches a blend of modern and traditional healing, medicine and midwifery and a biopsychosocial healthcare model. And she also combines science and research along with Chinese, Maya and African Indigenous techniques into her trauma informed practice and has more than 10 years of experience as a doula and a maternal health researcher and she’s a doctoral student in chiropractic medicine and very active at the national and local level. So Ihotu is really the perfect person to come on today and talk about the article that she authored as the lead author here at EBB. Ihotu, is there anything else you want to share with our listeners about yourself?
Sure. Rebecca, thank you for sharing all of that and it’s wonderful to be a part of the EBB team and also be working here locally in Minnesota. I’ll just share a little bit about my personal, how I came into this work. I’m mixed race. I was raised in a multicultural home and I have family and I travel often to visit them in rural Minnesota as well. New York City, I’ve lived many years and I also have family in rural Nigeria. So I’ve always had a really close relationship with a lot of different types of people and places. Rural and urban, white, Black, African, immigrant, progressive, also conservative politically. So I feel like that has given me some insight and maybe bravery to talk about culture and breaking down how do we communicate with each other and find common ground and just connect better as people trying to live.
And then Oshun is an African Ifa goddess of the sweet waters of abundance and sweetness and pleasure. And so she’s really celebrated in Black culture all around the world. And her energy in particular was really powerful for my healing through 2020 and the murder of George Floyd in my neighborhood in Minneapolis. So that’s why Oshun Center is named after her. Pulling from some of my heritage. And what I felt like we needed in Minneapolis as healers, as activists to bring sweetness into our activism. How to disagree, but with respect and how to be confrontational, but also maintain the relationship.
So I’ll just share a little bit about Oshun Center because it has allowed me to work with a lot of white allies as well as people of color and try to do some social experimenting around what is it that’s holding us back from being in better communication with each other? Where are white allies getting stuck in the work? And so we have built up a lot of programs around what we saw was missing here in Minneapolis with the racism here in Minnesota in particular. So we now hold peer consultation calls once a month with white allies to explore how are they doing their advocacy, especially in healthcare settings. How can they speak up, how can they show up? That’s called the Sweetwater Alliance. As well as we have healing spaces for Black and Brown people to work on and calm our traumatized, overworked, exhausted nervous systems and some of the issues that we struggle with having experienced racism for so long.
So we’re working on both ends and we’re also looking at ancestral healing, intercultural ceremony and how do we come back to maybe who we were before white supremacy and colonialism really divided us and made it unable for us to talk to each other. So that’s a little bit about me and my work and where my brain is going when we have these conversations and this research. And you can always follow my work on the Instagrams on social media, Ihotu Ali or Oshun Center, which is O-S-H-U-N C-E-N-T-E-R. And yeah, let’s dive into this conversation. I’m really excited.
Yeah. So Ihotu, you came on the team at EBB in early 2021 to help us with the Black Tiles Project, which is a project that rose out of a request from the Minnesota Healing Justice Network for us to help make the research evidence on racism and anti-racism in childbirth publicly available. Then over time we made the decision to put this evidence and try and compile it into one project and that became your main project here at EBB for the past year and a half or close to two years. And you are the lead author on this new signature article. I helped out where I could, but you took the lead. So can you talk a little bit about how the paper is organized? Because it’s a bit of a different signature article and it was also so broad in scope, we felt like we had to break it up into pieces.
Yeah. We had a lot of conversations about how to make this make sense for many different types of people reading it too. And so we’ve chunked it into about three sections. One is geared especially toward white allies, people with privilege who want to step up and help and offer support in this work and also do their own work to understand how they might be complicit in some of the things that happen. But from a framework of we’re all in this work together, we’re all on the same team, and how do we be more effective at trying to get to where we’re trying to get to? So that first section is called Solidarity and Soul Family. This idea that there’s a benefit of us being in a relationship with each other across difference. There are things that we all gain from seeing the world in a wider way from each other’s different experiences. There’s a value of this diversity and there’s a sense of family that we can build with people who are very unlike us in our family.
And what does solidarity look? So we lay out a lot of different frameworks and way to see solidarity as well as action steps that people can take that are very easy. How to talk to your kids, how to approach social media and lots of other things like that. And we also have prompts throughout that for you to stop, reflect on what you’re hearing, take a breath, don’t try to do it all one time, spread it out and make sure this is nourishing work for you too and joyful and expansive work for you too.
So then part two is really geared toward Black and Brown birth workers as well as people who want to get to know who are the visionaries in the field that we need to stand behind and support them and get their work more into the mainstream. This section is called Afrofuturism in Birth Work. I have a long time love of Octavia Butler, an Afrofuturist who use this idea that comes from African tradition like sankofa. We have to look back to go forward. We have to pull our history and understanding into being transforming in the future. So it’s about looking ahead and visioning. So not just saying all the things that are wrong. We certainly know that. The research reflects that. This is taking a step further and saying, what would it take for things to be different? What do we actually have to do? And so there’s a beautiful handout that goes along with this part two on Afrofuturism that looks at the Black Birthing Bill of Rights and it’s created by the National Association for the Advancement of Black Birth. We have their permission to create a chart that looks at several of those birthing bill of rights and says, okay, where are we currently? What do we need to do in order to make that right a reality? And specific ways that people can plug in small and big ways alike.
Then part three is one we’re going to talk about more right now and this one … So this is the big recap of everything. This is called the Evidence-based Equity Tools section. We’ll talk about an equity triad that really came clear for us in the research of looking at midwives as a really powerful tool in reducing the risk of mistreatment in birth and racial health disparities. Community-based doulas, which are different from the doulas that many of us know. It’s a particular type of doulas that’s grounded in the community and also takes a lot of work and there’s risk of burnout, which is why we need to support that type of doula work. And then also we wanted to uplift the idea of reparations and transformative justice because there’s actually not a lot of research in this area and we find it one of the three that is perhaps asking for more programs and work in this area in the future because accountability and addressing the harm and the elephant in the room for a lot of us is something that is harder to do and we’ll talk about that more in this podcast. But really, really important for resetting and getting to a place we’re all on the same page and can move forward together.
It was a big project. And I think obviously we’re encouraging people to go read the signature article and take breaks, but don’t stay away too long before you come back. And we did on the website make it really easy to jump from section to section. We have an introduction, the part one about solidarity and soul family, part two, Afrofuturism in Birth, part three, evidence-based equity tools and then the bottom line. Each of those sections has a table of contents, so you can easily find your way around and there’s buttons at the top of the page that take you to the different sections. So if you want to start with the vision of the future, you could go to the afrofuturism section to begin with. The evidence based-
And there’s handouts.
Yeah. And there’s links to the handouts. So it’s all right there at ebbirth.com/antiracism. That’s all one word. We’ll also link to it in the show notes. So with part three, part three evolved over time and one of the things we ended up adding towards the beginning was the definition of equity and what is equity and how is it different from equality. Ihotu, do you want to take that one?
Yeah. I think for folks who are wanting to get started, there’s these simple handouts you can look at. We have a getting started guide of just a page or two of resources you can look through. But as we deepen, we realize relationships are a big part of this work and in some ways disagreements and harms that have happened in our community is really important. So one thing I noticed is we’re not all using the same language. And so we wanted to clarify a couple of things here about when we talk about … The buzzword is DEI. Diversity, equity, and inclusion. So a lot of groups have done DEI trainings and different DEI programs and I want to be clear that that’s very important work. And also what we found in the research as well is that we have to go a little further than that and understand what really is diversity doing, what really is equity doing, what really is inclusion doing. So equity in particular, we want to talk about. Let’s break it down. A little language conversation.
A little [inaudible 00:13:27]
Make sure we’re all on the same page.
Equality. Martin Luther King, all of our civil rights leaders, beautiful people. Our ancestors talk about equality for all of us. Very, very important. Then we can talk about equity. So what really is the difference here? Equality would be everyone is treated the same. Standardized medical procedure. Equity, instead of what we are doing, we want to look at what happens because of what we do. The outcome. So equity would be looking at do we have the same outcome even if we applied perhaps not the same treatment to everyone? I would say that both are really important and equity is one step better. So for example, in many cases, birthing people of color may need more support and time with a provider because they might be experiencing because of their history, perhaps more discomfort in that room with that provider. Maybe more fear about what’s going on with them.
Fear of dying in childbirth.
Because of complications that they know are higher risk from. They might have more questions than birthing people who don’t have that conversation in their community. So you would think that maybe they would need more support. The evidence shows that Black patients actually receive less time and shorter visits with doctors even though they are experiencing higher medical risks. This is due to the racial weathering effect that we talk a lot about in the article and you can look up that resource as well. But you could really think about it like this. If someone has had several surgeries, several car accidents, we would expect a doctor to take an extra close look at their medical history, give them more time. Maybe they need an experimental treatment. Maybe the doctor needs some additional training or to bring on a consult to deal with that more complex case. But we don’t look at that in terms of race-based risk factors. So on a systems level, when we’re talking about equity, we might actually be advocating for a system where people of color or anyone who has increased risk gets the amount of care that they deserve and it might not be standard medical procedure. It might not be equal for everyone.
It might be enhanced because because there are-
Yeah. A higher standard of care. Because we know there’s a higher risk because of the way racism has changed outcomes.
Exactly. And instead we talk about equal sometimes when we should be talking about equitable. And I think this is where sometimes people disagree, and I think that’s understandable when we say, well, is it worth it to do the extra work, the extra time and resources it might take? But that’s a priority that we can decide on as a community. Maybe we want to raise the standard of care for cancer patients or for pediatric patients. It’s a decision whether or not we want to do that for people who experience racism or other forms of oppression. So I think that’s just a conversation in our field as healthcare providers and birth workers is is racism only a social problem or is it even an exaggeration of things? Do people not believe it? Or do we consider it a legitimate part of someone’s medical history and a reason to give them more care, especially through birthing?
Yeah. I often think that with people who are traditionally marginalized by the healthcare system and healthcare workers, that they do need more support, enhanced care. And for me, I work with a high risk population of pregnant teens and it always surprises me how they are often given less attention, less compassion when the group of teens that I tend to work with tend to have really high rates of preterm birth, preeclampsia, other health complications. To me, it’s a no-brainer. They should be treated with a heightened level of care and compassion and instead they’re not. And so I think you see the same thing with racism. And one of the things that really surprised us is when we first started drafting this article a year and a half ago, two years ago, talking about equity was not that controversial. I don’t remember it being controversial. And then all of a sudden it became politicized while we were writing the articles.
Yeah. It really did.
One of the things that happened while we were writing this article is that the governor of Florida signed the first US state law to make it illegal to have diversity, equity, and inclusion initiatives in Florida universities that were public and the Stop WOKE Act, which WOKE stood for wrongs to our kids and employees, put restrictions on teaching anything that could cause guilt, anguish or other forms of psychological distress related to your race, sex, or national origin. And to us, it was both ironic and saddening that the anti woke movement was co-opting a term that has traditionally been used by the Black community for close to a hundred years to remind each other to keep your eyes open and be wary of the life-threatening risk of racism in the United States.
And Ihotu knows quite well that racial justice movements in the United States are historically followed by periods of backlash. Where you have counter protestors arising and actively working to stop the efforts of racial justice advocates. And this ban on diversity and equity initiatives is a perfect example of this. We also saw the college board’s decision to remove Black Lives Matter from the advanced placement African American studies curriculum. We see it in places that are trying to remove mention of the race of Rosa Parks when she’s taught about in schools.
And even though it can feel frustrating and demoralizing and shocking and triggering, a backlash often appears after periods of rapid social change. And this is not new to this decade. And it also shows how much change and progress we’ve been making recently, that opponents are fighting the change with so much force. And I know Ihotu, for you, you’ve expressed to me that it can be really demoralizing, but it’s even more demoralizing when you realize that your peers and your allies aren’t recognizing different half-hearted efforts or when things are co-opted in your own community. And so the evidence on equity tools became an even more important part of our signature article on anti-racism because we not only wanted to highlight the equity tools that are supported by the evidence, but we want to provide some cautionary tales and nuance so you can understand how sometimes equity tools can be used for a personal gain or to reinforce racist systems instead of working for all of our liberation.
Thank you for sharing all of that. And I’m over here feeling all the feels.
But I think it has been hard as someone who saw so much attention and funding and offers of support come into my community and my organizations. As soon as it went off of the media, it was off of everyone’s minds. I know everyone is in a pandemic and we’re exhausted. I totally get that. But this article is really to help us do a little bit better and just learn what we don’t know and what would be helpful for us to know. For example, the difference between diversity and bringing people of color onto an organization and the difference between that and mending harm that’s in the room. I think that’s something I’d love to share here that’s a common thing that I’ve seen among white allies where they want to engage and support, but from a distance. And I think the US culture really doesn’t prepare us very well for dealing with conflict, for dealing with discomfort and sticky issues, for dealing with someone who says, you hurt me. And what do you say about that? How do you make amends around that? How do you repair? You’ve talked about repair culture in the article and being able to receive feedback in a way without being defensive is something I think we all can learn so much from and it comes up again and again in this work.
So there’s two examples that I always keep in my mind. For example, one, a hospital is seeing that they’re having poor birth outcomes with their Black patients, or they’re getting some discouraging feedback. The Black patients are not getting treated well. So one option that they could follow is to hire more Black nurses. Even better than that, hire more Black doctors or bringing Black leadership onto their senior leadership. Now, it’s easy to check that box, but then it’s harder to say, well, did it actually solve the problem? Are you getting better care? Because you can have people of color on staff and not change the system that is allowing the harm to continue and there might still be issues. And so you might want to really make sure that you are asking your patients, are you having a good experience? You’re looking at the numbers. And if they tell you feedback, even if it’s worded in a way that comes from their heart and their heart is really hurt at this moment, that you can still receive that feedback. So that’s one thing I think about is just checking boxes is not the same as looking at the outcome. Did we solve the problem?
And that’s where it’s so important to look at the nuance and the cautionary tales because you can’t just put a bandaid on this and fix it. It’s a much deeper wound. And you have a section on there about diversity versus mending relationships. It’s super important because it’s not easy. But I think also I love how you encourage people in the article when it gets tough, keep going, keep your thoughts and imagination centered on what it could look like. What the future could be. And with that, let’s talk a little bit about the evidence-based equity triad. And this was your idea Ihotu, because you really liked how the EBB childbirth class, we each have a three-legged stool. We demonstrate how evidence-based care includes three key parts. And similarly, through your research, you started finding that the equity solutions proposed by Black leaders and visionaries tend to fall into the three main categories. Number one is the midwifery model of care. Number two is community based full spectrum doulas. And number three is reparations and transformative justice in birth education and leadership. So I was wondering if you could talk a little bit more in depth with me about each one while we have this time here today. Is there a place you want to get started?
Well, we can talk about midwives.
We can talk about that. Yeah. So midwives, the research on midwives shows that they reduce racial disparities and the risk of mistreatment in birth. There are studies looking specifically at mistreatment rates. The challenge that we talk about in the article is midwives only attend 9% of births. Most of those midwives are white. And there’s a lot of history of harm from white midwives that we need to atone for in the community. And so there may also need to be additional training for midwives to bring back some ancestral pieces to the profession that was lost when it went through the licensing process in the United States and we eliminated the grand midwives and they are long legacy of working with families in the South.
So a few groups that we wanted to highlight that are offering scholarships to bring in more midwives of color into the field are the National Black Midwives Alliance, Melanated Midwives, the National Association for the Advancement of Black Birth. They all offer scholarships. We wanted to also uplift midwifery programs that are training more midwives of color like Jenny Joseph and Commonsense Childbirth. Sakina O’Uhuru and the A Wombman’s Way Warrior Midwife training. And then also midwives that are practicing in really traditional ways and expanding a little bit of what we think of midwifery such as midwife Okunsola of Jamaa Birth Village in Missouri that’s creating a postpartum healing retreat in addition to offering support for birth.
Yeah. But unfortunately, we also talk about the inequities and gate keeping in terms of how difficult it is to apply for funding, to get credentialed accredited for these training programs and the many roadblocks and dead ends that midwives have encountered when they’re trying to grow more midwives. And we talked more about this in the transformative justice and reparations section. Also, Ihotu, you did a lovely job writing about midwives and birth centers and other community spaces and I think it’s really important for our listeners to know that there is a newer nonprofit called Birth Center Equity. Provides financial support to established and emerging birth centers led by Black, Indigenous and other midwives of color. And also we give some action steps that you can take to support midwives and their ability to practice in freestanding birth centers. A great example is in Kentucky, which is the birthplace of Evidence Based Birth®.
We have zero freestanding birth centers. So any midwife, including Black midwives who want to open a freestanding birth center are not able to legally because there is a process called the certificate of need. And the last midwife who attempted to open a freestanding birth center in Kentucky in 2013 was blocked by nearby hospitals who argued during court hearings and won with the argument, “We don’t need a birth center because we have hospitals.”
And so I talk a little bit in the article about how there is a grassroots movement called the Kentucky Birth Coalition, which is led by primarily parents but also doulas and midwives and they are lobbying or trying to lobby to get Kentucky legislators to pass a bill that will exempt birth centers from the certificate of need. But just this year, the Kentucky Hospital Association, which has $17 million in assets and has the second-highest lobbying budget in the state, was able to oppose successfully this bipartisan legislation from passing that had enough votes to pass. But because the Kentucky hospitalization has so much power, they’re able to block it from getting a vote. And we also talk about how it’s important to donate to organizations that are grassroots, that are trying to get positive legislation passed and to keep supporting birth centers that are safe alternatives for communities where Black women and birthing people are facing racism in hospitals. Ihotu, you introduced me to a really interesting and innovative solution in New York City. Can you talk a little bit about that?
Yeah. Absolutely. So Birthing Place BX is a collective of birth workers in the Bronx, New York City. And they have been working to bring a freestanding birth center to the Bronx that is led by people of color. And so there’s been some delays in some of the legislative changes that they’ve been pushing for to make that possible so they have found a meanwhile a solution of creating a womb bus, which is just beautiful. If you look them up online, there’s a beautifully decorated little mini bus that travels around the Bronx, goes to parks, goes to folks.
It meets people where they’re at essentially.
In the community.
It goes to parties and baby showers and they offer community education out of the womb bus as well as supplemental body work services and supports community that way. So you can see them driving around until they … Well, maybe they’ll still continue it once they get their birth center, but they’re working on that meanwhile doing the work.
Yeah. And I’d encourage you to go to the article, look at all of the different birthing centers we were able to highlight and feature. I think Jamaa Birth Village in Ferguson, Missouri is an incredible example of a team that is creating a safe place for people to have their babies and to get support for all of their reproductive care. And you wrote that this is similar to the trend of maternity waiting homes across the African continent where people from rural areas travel early, stay in special lodging that provides them with a support system. And mentioning rural areas, rural areas in the United States have some of the highest rates of maternal mortality for Black women and birthing people. And so we mentioned The Birth Sanctuary, which is a birth center under development run by Dr. Stephanie Mitchell as well as other birth centers that are poised to be open soon. And just really trying to lift up the Black led collaborative midwifery efforts that are happening across the US. And we know we can’t highlight everybody, but we try to provide you all with some really inspirational examples of work that’s being done in communities.
There’s so many. And you can go on our birth justice page to find more or submit your models and information so that we can highlight that in different ways with our platform. There’s so many doulas that are providing now virtual services that can now span into areas where there’s not already doula services. I’m going to lift up Earth’s Natural Touch doulas, led by Scihonor Devotion that offers doulas for across 13 states. And so there’s so many areas where you can’t access midwives or you can’t access doulas. There are these registries. You can go to systemmidwife.com to find Black birth workers near you, but not everyone has access and so one of the areas we want to really uplift is supporting these groups that do exist so that they could expand or supporting new groups to start up.
And that brings us to doulas, which community-based doulas are the second part of that evidence-based equity triad. Can you talk a little bit about why you use the research pointed to doulas as being one of the three major parts of bringing equity to childbirth?
Yeah. So there’s a lot of really brilliant research that’s come out over the last many years around doula care. In particular, Dr. Rachel Hardeman has put a lot of great research showing that doula care for Medicaid populations is really impactful. That doula care reduces rates of C-sections, which then would have … The complications of C-sections can be really dangerous for birthing people of color. And so reducing the risk of those C-sections as well as complications. Preterm birth, which is something that comes up a lot in our community among the disparities research. And then doulas increase breastfeeding, which is protective for our babies, and then reduces the risk of mistreatment in birth because we’re there as advocates. I think that that also means that the community-based doulas who are essentially acting as buffers and experience a lot of vicarious trauma in the room trying to stand up for their clients when needed.
They’re going through a hard time. So it’s hard on community-based doulas. We work … And I say we, because I started out 10 years ago as a community-based doula in Harlem. We work extra hours. We are working with a lot of emotional heaviness sometimes. We are in the room where there might be very sticky moments or confrontation, things being said about the family or about us. And we have higher burnout rates because we tend to be paid less if at all. So now we’re entering this exciting time when a lot of different states are considering Medicaid and insurance coverage for doulas. But there’s definitely a lot of cautions around this tale because the states that have enforced Medicaid reimbursement for doulas have also enacted many different policies that have become gates. Gatekeeping-
A lot of doulas out. And so doulas have to register, they have to be trained with certain accredited organizations. They might have to pay a fee in order to get on the list. And so it begs the question, the things that happened with midwifery a generation or two ago around the licensing and how that changed the profession and changed who’s in the profession, begs the question, will that happen also with doulas unless we’re really careful about how we do this?
Yeah. We talked more about that in episode 229 of the EBB podcast about the community-based doula model. But can you briefly tell people what you typically think of as a doula and how a community-based doula is different? Because I’ll talk to a lot of private doulas who are like, “But I serve my community, so why am I not labeled a community-based doula?” Can you talk a little bit more about what a true community-based doula program is?
Yeah. And community-based doula is a term that we use to describe a particular community. Everyone is a part of their own community, absolutely.
This term specifically is looking at how do we do prenatal visits, how many prenatal visits and what are we talking about? So a traditional doula might do … I remember when I was initially trained with DONA a long time ago, it was two prenatal visits, attending the birth. That conversation was a lot about the stages of labor and then going through the pushing process and breastfeeding in the first hour and then one postpartum visit to retell and recap the story of the birth. Flash forward to my life as a community-based doula. And this is mentioned in the paper as well is how hard it is to even do the financial. How do you create a financial model around this? Because when I was a community based student in Harlem for teen moms or single moms or African immigrants who had newly come to the country who spoke French, they were calling me at all random times. We might not have specific postpartum or prenatal visits. We’d meet up here and there. There might be a stretch of time when I’m out of touch with them, and then they might call me when they’re already in labor, and then I’d come quick. And then there might be other people. Maybe they had extra family who came to be there for the birth and so maybe I would step out to allow that family to be there.
And then maybe in the course of the birth, yes, I’m helping them with pain management and walking them through the process, but I might also be dealing with having to talk with doctors and nurses who are treating them badly or I’m having to support them when they’re going through a near miss experience and a near miss is when it’s not a general death, but it’s a severe complication that could have led to death. And so I’m way more comprehensive emotional support person be. I’ve been translating between French and English for clients, and it’s more like a social worker, counselor, much more involved role than I was initially trained in with DONA as a doula.
And you may be giving more intense postpartum support. You-
For years. I still get calls from some of them.
And normally a private doula would be on call starting at 37 weeks. But as a community-based doula, your population is at higher risk for pre-term births so you could be called at any time.
Or coming in to help them If their blood pressure is up. I’d be going in to visit with them for that.
And typically, community-based doulas are members of the community that they serve. So if they’re serving a traditionally marginalized community, they’re part of that community. They’re embedded, and that is their community. Whereas a regular private doula may or may not share similar characteristics with their client. It’s I guess probably more of the private model. I don’t know the best way to say it. One is driven from the community and is much more intense, but often offers lower wages or no wages at all.
Right. Equity, equality conversation.
And one of the things I love that you added to the article was remembrance and honoring the life and legacy of Loretha Weisinger. Considered by many to be the mother and founder of the community-based doula model.
And thanks to Denise Bolds for bringing her to our attention too. We had so many birth workers that added pieces that made this paper more robust. She was trained by HealthConnect One, which is the largest as far as we found doula training organization and they offer trainings for community-based doulas around the country. I should say the largest community-based doula training organization. So you’ve really created a model of what the community-based doula looks like and it’s different. It has to be paid differently. It begs the question, should we have the option as doulas to be employees of an organization with salaries and benefits? Would that help elevate the profession, allow more people who are not of privilege to actually take on this job? Because a lot of us burn out because we didn’t come in with money, and then we don’t make much money, but this is an evidence-based equity tool that’s needed if we want to raise that standard of care around race disparities in our healthcare system. So wee need the-
I think it’s important. You give all these examples of people already doing this work. They just need more support, more funding, more resources. And I love how this section has really evolved to just lift up people who are doing the work, different coalitions, different programs all across the US and ways to support them and reach out. And then also going into the nuance of the whole idea of how we pay doulas. How commonly, if you want insurance reimbursement, you get the two prenatal visits, you get the birth attendance and one postpartum visit, and you make the point that this model was developed by white middle to upper class doulas and doesn’t serve all communities.
Right. Right. Anyone with chronic illness, with trauma, with disability is going to need a different model perhaps. And so we should create policies that reflect that. I hope that we can share this podcast with policymakers who are looking at creating legislation. This is the information that we’ve been told by birth workers is what needs to be considered as we write new legislation, as we train up new doulas. So I hope folks take a look at the article and dive in.
Yeah. Start going down-
And also understand that it’s not only about money. It’s about having the skills and understanding the lessons learned that are written here. And if you don’t have a lot of money … And as we’re recording this, we’re in a possible recession and things are tight. But what I found with working with allies here in Minnesota is there’s a lot you can do on a dime. There’s a lot you can do on building a relationship, on connecting someone with an email, on not being scared when you ask how to help and someone just gives you a laundry list of things that they need help. And you say, “Okay, I’ll not try to do this by myself and burn myself out. I’m going to go and talk to some other folks. I’m going to find a local organization, and we’re going to see what we can find just amongst the community connections that we have to bring support.” Because that’s what’s been really discouraging is people who say, “Yeah, I want to help. I want to help.” But then they get scared or they’re uncomfortable with the feelings that we have.
We’re excited. We want to create change. And then we have things that we have ideas, and if people just back away or don’t come through or don’t sustain that relationship, that’s just personally hard to take when this work can be very simple and we can all be nourished and do it together with what we have. We don’t need to be millionaires or have unlimited time to make this happen. What we have to do is get out of the idea that we’re alone and really agree that we can do this together.
I think the old saying don’t reinvent the wheel is really important because … We talk about this in part one on solidarity, but white well-meaning allies often think, well, I’ll start this, or I’ll do that without even realizing that there’s already people, already Black women and people who we need to be following and just lifting up their work and lending our strength to their efforts because they already have the solutions. So that’s one thing that I love about part three on equity is we’re highlighting, here’s solutions. Here are people doing the work. So the last key of the triad, we had midwives in community and community-based doulas. The last part of the triad is a little bit harder to talk about, and that’s reparations and transformative justice. And this came from our review of the research and the literature and just realizing that the big missing piece is the lack of accountability when there’s harm.
This is the elephant in the room for many of us is how do we bring change against really large players who are not interested in changing. I think what we have in this area are groups like the Maternal Mortality Review Commissions that are across many of the states in the United States that are reviewing the cases of maternal deaths. There are still some limitations around that. We’re not reviewing morbidity cases or near miss case of near deaths. We’re also reviewing cases once people have already passed, which is difficult. And I’m a member of the Minnesota MMRC, and so we have these discussions internally, but I think that’s one of the few tools we have of going back to hospitals with this data and saying, these are our recommendations. I think that’s really powerful places to bring the recommendations to hospitals and to create state reports on what we’re finding in the data. I think on an individual level, people are bringing lawsuits. People are bringing civil rights lawsuits to hospitals after a death. In all these cases, they’re after a death, which is absolutely heartbreaking. We don’t have many financial and performance measures based mechanisms.
Meaning that we’re still just reimbursing and paying for a check on a checkbox and not for how was the care delivered? Was it delivered with skill and compassion in a way that prevented mortality? Or was it just the bare minimum or perhaps even not even the standard of care?
That, and were not asking patients really, what was your experience and taking that into account. It’s really hard to submit a case in that way of misconduct and to get an actual response back from a hospital with even an apology. I understand there’s a lot of legal shrouding in this area that makes it hard for hospitals to engage in a simple conversation where someone can say, it was an accident, or I’m sorry, or I’ll do it differently next time. We’re not able to get into those conversations. I think also there’s been a little bit of talk on the federal level of tying payment to hospitals based on their outcomes or based on the fact that they have engaged in some kind of DEI or equity work.
I think we talked about a lack of hospital accountability. When Cristen Pascucci came on the podcast, it was episode 170 about mistreatment in childbirth care and how filing a complaint with the hospital, it’s like asking a restaurant, she used this example, to hold itself accountable when it causes food poisoning. There’s no incentive for that restaurant to come out and say, “Look, we caused all this food poisoning. We’re sorry. We’re doing things differently.” No, the health department has to enforce that.
And with hospitals, there’s almost no accountability for racism, for maternal mortality. I know here in Kentucky, the Kentucky Hospital Association, which so strongly opposed birth centers and midwives when we were trying to get midwives legalized, they used all kinds of dirty techniques to suppress their competition. One of the worst things they did was talk about … They actually co-opted the maternal mortality crisis and said, this is why we can’t have birth centers or midwives because they’re dangerous. And I wanted to be like, where are the birthing people dying right now?
That’s exactly what was used in 1921 with the Sheppard Towner Act. Where they said that it was the midwives’ fault that babies were dying. And when they went through all of these processes to licensed and basically eliminate many of the grand midwives, then it came out that it was actually poverty that was impacting the mortality rates, not those midwives. So if we don’t have actual data … And we actually do [inaudible 00:49:09]-
And that’s when I want to be like, well many babies died at this hospital in the last year? We don’t know. They don’t report that data. There’s no transparency. There’s no accountability. There’s no apologies. And so can you define for our listeners who don’t know what transformative justice is, can you explain what that means?
Yes. Transformative justice is an approach to doing things differently about causing harm and making things right after harm occurs. There is a fantastic video that’s in the paper by Adrienne Maree Brown that has a beautiful description, but it’s really about transforming the way that we see justice out of a model where we blame people, we don’t have conversations about it, we lock people away.
And we sue them.
Or we sue them. Like the throw away culture. Even cancel culture. Even as important as speaking up against wrongdoings is, it’s very important to speak that out, but what are we doing to repair the harm after we’ve spoken it. It does not get better just because we spoke it. Now we have to also do the mending work, the repairing work, the restoring back to a healthy place where we are in relationship with each other and we’re not throwing anyone away. That people have learned and changed. We understand you might not be able to reform everything, but can you transform it to something that is even better than what it was?
And you make the point, we’re going to continue to have these high profile deaths, Black maternal deaths, until there is some accountability, change. Until they change their ways.
And the deaths aside, what about the small slights that happen all the time that we’re afraid to speak up to? That we don’t know what to do in that case. And so that’s why in this article, we offer scripts. We offer charts and examples over and over and over again of what you can do in small ways to speak up, knowing that if you do come from a position of privilege, you speaking up, there might be a small risk. Maybe you get a slap on the hand or something. There are people who with less privilege could lose their jobs. With less privilege, could be in a really challenging situation. And so we’re asking people to also weigh, are you in a position where you could speak up and say it out loud in a way that other people can’t?
Yeah. I love how you talk about how there already are movements. Don’t reinvent the wheel. There is a movement of restorative and transformative justice that came out of prison abolitionists. And that actually happened in my community a few years ago. There was a break-in at the place of worship I go to, and they broke the windows and tried to steal the petty change. It was a simple crime, but it was expensive for our church to fix. And the police, they actually checked for fingerprints and found the person and they came to us and said, “Here’s what you can do. You can charge them, or you can go through this transformative justice mediation process with them where the pastor would actually meet multiple times with the person and figure out how they would make it right.” And it was like, oh, this is an option? Especially for a religious body it felt like a really good fit. And so I love how you talk in the article about what if we made something similar in birth? What if we could imagine over the next generation a way to take painful experiences and turn them into powerful moments of change where then the next generation doesn’t have to experience this pain?
Yes. And just be creative wherever we have a field of influence. Could be small. We work this into our own families where we can have something harmful happens and we have a conversation about it. By the way, this is all coming from traditional Black and Brown cultures that have this. This is practiced in my own family. My grandfather, who’s picture is right here, was the head of the council of elders in our community, in our village in Nigeria. And so there would be people come together and you have to exchange some kind of gift, and you have to make these symbolic gestures that we’ve told our stories, we’ve been heard, now someone has made some kind of judgment of this is how we’re going to settle the matter and we can move on. And there’s a sense of your heart can breathe a little bit lighter because you’ve resolved it.
You don’t forget, but you’ve resolved it. I have to tell you one quick little story. So I was trained as a restorative justice volunteer for a group here in Minnesota that works on an alternative consequence for juvenile offenders. So they showed us this video, and you can find this online too, where an RJ group out of California had a case where someone came in and maybe they were doing stealing or some kind of story. So this person who had stolen was sitting with the woman who had her purse stolen and they’re having this conversation. And it’s a very heartwarming story of how they start to find some common ground because now they’re talking as two people in a room that’s also mediated and held. And they start to ask this question of what would make it right? Because you can’t go back. Maybe they’ve returned the money, but that experience, you can’t go back. But what would make it right?
And it turns out that the young person is an amazing artist, and this woman who had her purse stolen loves art. And so she asks if he could make her a huge Tinkerbell art piece. And it’s just so random, but he really gets into this idea of being able to … He can’t pay her back all of that experience. He doesn’t want to go into a criminal justice situation, but he can make this beautiful art piece. And so there’s just this very cheery moment when they find a random alternative to holding onto this anger or this guilt or hurt forever. And so it’s this power of what a conversation can illuminate.
But then also having the accountability with the conversation. Because I had the honor of supporting someone when they were having a virtual meeting with the hospital that had harmed them. And at first they didn’t want to let me be in the meeting, but she basically said, “Rebecca’s going to be there.” And I was there and I listened. And I think they came short of a true accountability, but the doctor that was present did apologize for the hurt that the person had experienced. And they talked about how we do want to do training with our doctors. But then after that meeting, it all fell apart. And it was because the doctor was essentially lying to us. She wasn’t sorry. They weren’t going to make any changes. She was just saying what she had to to get us to go away. And that was a really eye-opening moment for me because I was like, how do you know that there has been a true change of heart and that they’re not going to do this to another person?
And that is a story for so … We talk about in the article, many groups that have caused harm to other groups, associations. And there’s a lot of lip service and not actual change. I’m not sure why people are so hesitant to change.
Well, yeah. I’m sure we could write a whole nother [inaudible 00:57:18] on that. I had something I wanted to bring up. This is not in the article. This is something I read this morning. Okay, I’m on this email list and they’re talking … Okay. The email said, how much can we expect institutions to care about us as individuals? The Supreme Court of the US may view corporations as enjoying some of the same rights to freedom of speech as persons, but psychologists often describe the behavior of corporations as psychotic or psychopathic because they can’t feel guilt or empathy.
And I can link to that newsletter in the show notes, but it made me think about a section that our reviewers asked us to add to this. There was a section called Transformative Justice in Leadership Challenges, which describes several cases in which new Black leaders in previously or historically white led organizations were fired, pushed out, removed or ignored soon after taking office in some cases with no transparency or no true just cause. And that was not something we were originally going to have in this article. But again, like you said, this whole section is the elephant in the room, the harm that’s caused, and what would transformative justice look like in situations where there’s organizational harm in our own field?
Something that we have to figure out as a field. What are our values? Is it okay to just do status quo and dismiss things that-
And move on.
Yeah. Just sweep it under the rug. I have to say, did the pandemic teach us nothing? We had this moment of saying, no, we are not going to just do status quo. We’re going to stand up. The Me Too movement. We are going to stand up and speak about these things and have a conversation, and here’s the piece, figure out how to mend it. Not ignore it, mend it. That means sitting down with someone that you may 100% disagree with what they say. That’s okay. We’re never going to agree. Agreeing is not the issue. It’s about listening and actually believing, wow, maybe I need to tweak something about what I do. For all of us. Me, as a light-skinned Black woman, I need to tweak things about what I do too.
And I need to speak about the things that are harming me, otherwise that person isn’t going to know, and hopefully that person is going to be okay with me saying that and will actually tweak something for them too. We’re not saying anyone is … I see this come up with a lot of white allies where if you say something, it’s like everything crumbles and I’ve insulted their entire being. That’s not it. I have a lot of respect for the strength of a person that I believe they can handle what I need to tell them. I try to say in a way that’s respectfully but also direct. And if I don’t think they can handle it, I won’t tell them. If no one is telling you anything about yourself, you’re not getting the real picture. But If people are telling you, I take it as a compliment and I give myself 24 hours at least to not say anything. Just say, “Thank you. I’m going to sit with this.” And go and sit with myself and remind myself I’m a good person. I’m doing all the things, and this is a blind spot, and a blank spot that it’s okay for me to improve on this area. Someone’s inviting me to improve. And I take that as a compliment that I could handle it. That they thought I could handle it.
I love how this is all circling back to part one where we talk about solidarity and what is white culture? And one big part of white culture is focus on the binary, either good or bad, you’re evil or pure, you’re on one side or the other and there’s no room for that nuance of just because I need to improve in this doesn’t mean my whole life is a waste, or I’m worthless.
No. And yes, that binary makes us … If anyone says anything, then we’re bad and that’s not it. And that’s what transformative justice says. There is not just good and bad. We all harm each other. We all help each other. And we can have these conversations to tip the scales more toward healing. But it should not come as a surprise that we harm each other sometimes. Of course.
We’re all different.
And I guess it shouldn’t be a surprise that people are resistant to change or to feedback sometimes. Actually, this comes up so often in my life and in our field, the whole concept of defensiveness that I actually checked out a book from the library all about defensiveness, written by a psychologist.
Oh my God.
I’m here late night reading. What are signs of defensiveness? How do people react? Why do they react this way? It was a really interesting read, and I can link to it in the show notes. I can’t remember the name of it off the top of my head. You write in the article about the need to have an openness, a willingness to perhaps be in a circle type atmosphere where we talk about what’s happened and is there a way to repair this harm? And I think sometimes I’ve seen this a lot in birth workers is that they don’t … And I’m sure this happens in other fields as well. Nobody wants to admit any wrong. It’s as if saying I messed up is akin to saying you’re a worthless person. And so you will at all costs, avoid apologizing, avoid saying that you could have done something better.
And we’ve learned, I think for many of us who identify as women or feminists through the Me Too movement, that true apologies are extremely powerful and healing, wherever it comes from. And I would love to see more space given to true apologies that does not just incite more lawsuits because lawsuits are very painful processes as well.
It can’t just be words though. It has to be some kind of change to go along. Change in behavior. And that’s where the accountability comes from. And I hope that you all will read the article and maybe come to the same conclusion as us, maybe not, that this whole concept of accountability, transformative justice, reparations, needs to be part of that triad of bringing equity to birth. Because without it, unfortunately, unless we have that process, we’re not going to see change from where we need the people to change. We can grow all the baby midwives and doulas that we can, but if the system itself and the people within that system aren’t changing, then we’ll continue to see midwives and community-based doulas burnout out and not last in the profession.
So Ihotu, I feel like this is the time you would be reminding us all to breathe.
Yes. Take a breath. We covered a lot of ground and some light and nourishing stuff as well as some heavy stuff. So pay attention to your breath and your feet on the ground and the earth beneath us, holding us all up so we don’t fall. We’re not falling, we’re all standing. If you are seated, however you are in space. In the words of Oshun, the sweet waters, keep sweet waters near you too. There’s water goddesses across all the different traditions. So drink water, get some fresh air, and thank you for joining us for this very in times spontaneous conversation about what’s happening in our field. Where do we want our field to go? Who do we want to be as birth workers and what are the foundations that we’re going to lay out for the next generation of birth workers after us? They are watching.
We are grateful for all of you who are listening or watching and continuing your learning with us. And like Ihotu said, take care of yourself today and maybe think, feel in your body, but also think what’s one thing that you took away from this conversation that you’re going to remember and put into practice in your community or in your life. Thank you everyone for joining us today, and we will see you next week. Bye.
This Signature Article focuses on the Evidence on
Anti-Racism in Health Care and Birth Work:
Shifting from Statistics to Solutions, Solidarity, Afrofuturism, and Tools for Protection
Download our Free Handouts on this Topic
Or check out the Birth Justice page for more resources!
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:
- Solidarity & Soul Family
- Afrofuturism in Birth
- 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.
Part 1: Solidarity & Soul Family
Part 1: Solidarity & Soul Family - Table of Contents
Utilize the table of contents below to jump to sections you would like to read and work through:
- How do white cultures practice solidarity and family? (And what IS white culture?)
- A message from Rebecca: A message for white readers on “allies” and “accomplices”
- Stepping outside the “white privilege” box: A whole new world
- How do you start taking the first steps?
- Expand your Resiliency
- Your Effectiveness
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:
- 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.
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!
Start a daily or weekly anti-racism or anti-oppression practice and journal to continue through the year, like Rebecca’s suggestion in EBB Podcast Episode #200 to keep a book on social justice at your bedside at all times. Regardless of our background, we can always be learning and expanding our self-awareness! You can also sign up for daily or weekly emails from Anti-Racist Daily for fresh ideas and resources.
If you’re a birth worker or health care worker, notice the words, behaviors, and non-verbal cues of white health care workers when they interact with a Black client. Do you see any differences in how your clients are treated? Write down what you see and hear. Reflect on what you felt in that situation. Did you feel anger? Overwhelm? Did you freeze? Did you speak up? Try not to judge yourself for how you “think” it went, and instead reflect on how you’d like to handle these scenarios in the future. You can write out sample scripts for yourself to keep in your birth bag or office, or to practice with a friend.
Many of us were taught to say and feel nothing when we encounter racism. We invite you to change that pattern, by noticing what you feel, and preparing to speak up while staying grounded. You can keep it simple! We will offer you some sample scripts to follow, later on in the paper.
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.
Book clubs and anti-racism discussion groups became very popular in 2020, but author Layla F. Saad cautions that without clear guidance, some white supremacist behaviors (such as a power hierarchy, white centering, white fragility, etc.) can start to creep into solidarity discussion groups. For these reasons, she requests that people who want to do a book club with her impactful book, “Me and White Supremacy,” use guidelines from The Circle Way. The Circle Way puts equity and justice at the center of group meetings through a “lightly formalized, lightly facilitated social structure that allows people to use circle process in a wide range of settings.”
You can also explore public curriculum like this one created by medical students, or consider joining existing organizations that host virtual or in-person discussion groups for white allies, such as Showing up for Racial Justice or the Oshun Center for Intercultural Healing.
Rebecca suggests using journaling or therapy sessions to analyze the racism in the world that’s around you, with a particular focus on how you have played a role in a racist environment.
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.
Action Idea at Home:
When children notice different races, or see injustice or news about racism, talk with them about it! You can agree that, yes, we have different skin colors, just like eye colors, hair textures, and body shapes, and explain that on the inside, we are still all the same. (Thanks to the Human Genome Project, we know that humans are 99.9% genetically identical!) If age appropriate, you can explain that higher levels of a protective pigment called melanin is what makes some people darker (because their ancestors lived in places with a hot sun), and that most of us get a little more melanin when we stay in the sun too long!
White parents can point out inequities and prejudices and how it’s important for us to speak up when we notice that things are wrong. It can be hard for kids to process injustice—hold space for them to grieve if they feel sad. It’s okay for it to be hard. We don’t live in a perfect society, and we can’t pretend like “everything’s great” when it’s not. The kids will be okay—they can learn about hard/sad topics and still have a wonderful childhood. As Rebecca says, “If Black parents have to teach their children about why they experience racism, white parents can certainly teach our children about racism and how to be anti-racist.”
For more ideas on educating children, check out Antiracist Baby and resources for children and teens on Ibram X. Kendi’s website, or a book box subscription designed for hard topics, or the Woke Homeschooling curriculum (Rebecca and her older children used the U.S. History curriculum during their 1-year stint of homeschooling and they say they learned so much!).
Pause, breathe, and notice your body’s response.
Action Idea at Work:
Take note of racial diversity among your colleagues and senior leadership team, and if there are racial (or other) gaps around pay equity, access to paid leave, and other benefits on paper or in practice. Has your organization made any public statements after major tragedies, or set internal goals for practicing racial justice, equity, and inclusion? How have they been implemented and sustained?
Do employees of color experience microaggressions? Are they given space to offer feedback and suggest changes if issues arise? Is there a sense of team support, ethical leadership, and care for people’s mental health and life outside of work, regardless of their race, gender, or other identities?
You can advocate for training in implicit bias, self-awareness, and reducing common characteristics of white supremacy culture (such as perfectionism, urgency, and fear of open conflict) that are present in most workplaces across the United States. Decolonizing our workplaces, especially for health care workers, can have a powerful ripple effect on how people experience health care, and the way we care for each other.
Pause, breathe, and notice your body’s response.
Action Idea Online & In Community:
Social media is a place to practice racial justice with caution because it can come off as more performative than genuine unless it is coupled with your actions offline. Social media is a great way to connect and build new relationships, share your opinions, and showcase news and facts to educate others, but keep in mind that it is often “preaching to the choir.” The people who are “friends” with you or follow you on social media chose you because they already agree with your activism, while those who disagree simply tune you out or click “silence posts from this person.”
In addition to sharing online, consider the power you hold to influence those who already know or may look up to you – a family member, a colleague, a local business owner. Make a commitment to sharing your values openly, from your heart, in ways that are not shaming but inspiring to others. If you’d like some help in starting sensitive conversations, try wearing t-shirts or buttons with phrases that reflect your values, and keep the conversation going if someone asks about them! You can also practice bringing up news or current events in gentle ways, to open the door for conversations and teachable moments.
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!
Make a short list of local, national, or global leaders in anti-racism in health care and birth work that you deeply admire and would like to get behind (this paper will highlight several voices you might choose!). Join their email newsletters, follow them on social media, support them directly via platforms such as Patreon, and consider signing up for any classes or programs they run. If they start a new program or fundraising campaign that you can’t support yourself, make it a point to send their information to colleagues and friends who might be interested, and put in a strong word to encourage their support. If you know them personally, make a standing offer to watch their kids if you have extra time, or buy them a meal or a self-care/healing session if you have extra funds! We know that time and money is hard for many of us, so think creatively about ways to support that are honest, simple and sustainable for you.
If appropriate, make email introductions to help expand their circle of influence to include philanthropists, media contacts, legislators, and send them opportunities for grant funding, training, and fellowships. Find creative approaches to connect and amplify their work in ways that don’t apply pressure or change their natural pace or priorities, or demand too much of their time and energy. They may need time to integrate their own changing leadership style – be sensitive and patient, but also consistent in your support. Remember that from a non-white cultural perspective, their success is also your success.
Pause, breathe, and notice your body’s response.
Part 2: Afrofuturism in Birth
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 firstname.lastname@example.org.
Part 2: Afrofuturism in Birth - Table of Contents
Utilize the table of contents below to jump to sections you would like to read and work through:
- Hope is a discipline
- A Word from Ihotu – On how Afrofuturism can bring hope and healing
- Imagine a Different Future
- Black Visionaries in Birth History, Arts & Culture
- Acts of Resistance Against Tragedy and Fear
- Black Visionaries in Birth Technology & Innovation
- Using Social Media for Exposing and Organizing
“Hope is a discipline”
-Mariame Kaba, Transformative Justice Advocate and Organizer
Afrofuturism, also known as Black Futurism, is a cultural philosophy and movement led by Black science fiction writers, artists, and musicians like “Genius Award” MacArthur Fellow Octavia Butler , Sun Ra, Janelle Monae, the movie Black Panther, adrienne marie brown and other contributors to the anthology Octavia’s Brood. Afrofuturism is both a spin on science fiction (putting Black characters at the center) and a philosophy embraced by those who dream of a Black Utopia that is both futuristic and ancestral.
Ytasha Womack, author of the book Afrofuturism: The World of Black Sci Fi and Fantasy Culture, explained at a 2017 lecture in Amsterdam:
“Afrofuturism is a way of looking at the future and alternate realities through a Black cultural lens. It is an artistic aesthetic, but it is also a method of self-liberation or self-healing. It can be a part of Critical Race Theory, and it can be an epistemology as well. It intersects the imagination, technology, Black culture, liberation, and mysticism. As a mode of self-healing and liberation, it’s the use of imagination to help people transform their circumstances [because] imagining oneself in the future creates agency.”
Afrofuturism also carries forward an ancient African concept called Sankofa, a word from the Akan people of Ghana, that calls us to look back into and learn from our history, so that we can move forward with wisdom. Many Black birth workers use references to this cultural aesthetic in their work, such as homebirth midwife Tina Braimah in Durham, North Carolina, who owns Sankofa Birth and Women’s Care , and Chanel Porchia of Ancient Song Doula Services in Brooklyn, New York City. Loretta Ross, one of the founding voices on Reproductive Justice (which we will discuss more later), has also spoken on Reproductive Futures as a part of Black Feminist Theory.
Elder Midwife Claudia Booker and other birth workers have even described birth as futurist – as a gateway for change, a portal, or crossroads moment between the past and the future:
“Birth is a physical occasion for metaphysical change. We doulas understand that birth is one of those occasions when the past, the present, and the future all align in the room together. That’s why prayer, that’s why ebo [offerings], that’s why spiritual incantations. Make the vibe, make the way open for the present and the past and the future to all be together, to all host the new life, and not only for the baby being born but the new life of the pregnant person, of the mom, of the parent, the family, of the community. A new life for each and every person that’s in that room.”
(In the Light of Birth with Midwife Claudia Booker!)
In birth we welcome new life, tell stories of ancestors, and carry forward family traditions. We choose to make major life changes, such as focusing more on our health, our home life, or ending harmful family patterns that no longer serve us! In raising children, we shape the future. Birth justice can be seen as an act of protecting Black, Brown, and Indigenous lives, as well as our shared collective future.
If you are a white birth worker, ask yourself, how much do you know about Afrofuturism, Black Joy, and Black Excellence? What topics come to mind when you think about Black culture, and which of them are joyful, healing, or representing excellence?
Many of us may miss an important nuance when we educate ourselves in ways that teach us to see racial groups only as vulnerable, suffering, or having to be excessively strong to survive and succeed.
Afrofuturism allows us to also see creativity, play, imagination, and beauty in Black culture. Challenge yourself to do an internet search for some of the people named in this section, to open your eyes to new ways of thinking, being, and living inside of Black culture!
Pause, breathe, and notice your body’s response.
A Word from Ihotu – On how Afrofuturism can bring hope and healing
Growing up as a mixed-race child in small towns in both Nigeria and Minnesota, I have often felt like a science fiction character. Although I identify as Black, I live at the intersections of Black and white, American and immigrant, urban and rural. My parents met a few years after Loving v. Virginia was won – the landmark legal case that formally allowed interracial couples to marry – and I grew up hearing stories of racism they continued to face in southern Minnesota. They named me Ihotu (pronounced ee- ho-too), meaning “love” in my father’s language, Idoma, as their own intergenerational act of resistance.
I was raised to not see race, but I attended mostly white schools in segregated neighborhoods that taught me plenty. Instead, I was raised to deeply see culture, to spot the nuances between American values and African Indigenous traditions in how we communicate, care for our families, respect our elders, and follow our inner purpose. Eventually I moved to Harlem, New York City, to learn more about U.S. Black history and culture, to attend Columbia University as an awkward first-generation college student, and fulfill a dream of traveling across Africa as a maternal health researcher with the United Nations.
I worked alongside midwives, community health workers, obstetricians, and epidemiologists in the Democratic Republic of Congo, Haiti, and dozens of countries using research in hopes of improving their maternal health systems. Along the way, I took a doula training that lit a spark in me and changed everything! I had become disillusioned with the slow rate of change through research, and instead I became a doula and community educator, managing health programs in Harlem, working in policy coalitions with midwives and doulas across the state, and testifying to the New York City Council as part of the first waves of public doula funding in New York City. Back in Nigeria, my grandfather had been a traditional village chief and head of our Council of Elders, and was highly respected as a community father, judge, and conflict mediator. He was said to have held onto the “old ways” of spiritual healing despite pressure from Christian missionaries, and was skilled in resetting dislocated shoulders, which he did for me as a child. I was said by many to carry his spirit – his calm and careful words, his sense of tough love, and his value of culture, simplicity, and community over fame or material riches.
I’m sure much of his influence led me to “keep going” once I became a doula. As if trying to resurrect the multipurpose traditional healer I had seen in him and others, I’ve followed this passion for years, learning Black, Brown, and Indigenous cultural traditions in birthing, healing and conflict mediation, including massage, Maya abdominal womb care, chiropractic medicine/bone setting, transformative justice, spiritual baths and cleansing, grief and rage rituals and more.
By 2020, I had moved back home and was living in Minneapolis, Minnesota. George Floyd was murdered ten blocks from my home. I remember the shockwaves ripping through our community like it was yesterday. The Minnesota Healing Justice Network Facebook group of birth workers, bodyworkers, and community healers of color saw its membership triple in days. As a group of over 100 healers, we offered care to protestors and displaced residents and coordinated Black and Brown retreat spaces for the public. Rolling Stone Magazine captured a glimpse of how we protested and held space for hope and futurism even as our neighborhood grocery stores, clinics, and Black and Brown community businesses burned to the ground.
Amid what felt like a race war, I carried DNA and love from both sides, and felt more than ever like the misfit in a science fiction story. Black futurist stories by Octavia Butler were the only places I felt articulated the complexity and emotions of my experience. Two of Butler’s classic texts, Parable of the Sower and Wild Seed, gave me creative and profound ways to understand the human condition, injustice, healing, and a moment to transcend this world and find solace in imagination. A powerful review on National Public Radio describes Butler’s work as having a “message of hope conjured by centuries of survival and persistence. For every society that perishes in her books comes a story of rebuilding, of repair.” Learning the bold ideas of Afrofuturism and Anishinaabe Elder wisdom such as the Seven Fires Prophesy deeply inspired me to use my identity and experience as a bridge-builder, and I felt a nudge to say yes to this project. Around the same time, I also founded the Oshun Center for Intercultural Healing in Minneapolis as a space for cross-cultural dialogue, intergenerational and soul healing, and reclaiming cultural practices from the midwives, bone- setters, and traditional healers across all our ancestries. More than ever, it feels important that we look back, in order to go forward. So let’s dive in deeper!
Imagine a different future
We invite you to join us in a visionary space, where Black birth is NOT known by its mortality statistics, disparities, or fear or conflict in the birth room. In this vision, we center Black and Brown safety, dignity, informed choices, abundance, family support, healthy children, and joy. This is different than colorblindness, toxic positivity, or downplaying our current realities of pain, rage, and the challenges and risks that come along with speaking up and making change.
Afrofuturism envisions a world that doesn’t yet exist, but that we intentionally nourish in our imaginations and in consistent, lifelong actions. This is based on the idea that we can’t create change unless we know what we are working for (not against!), and also that if we can dream it, we can build it.
It may help to paint a visual picture with the question, “What would birth and parenting look like in Wakanda?” (If you’re not familiar, Wakanda is the mythical African country featured in the movie Black Panther!)
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.
Table 1: Examples of How We Can Take Action to Support the Black Birthing Bill of Rights®
**TRIGGER WARNING: MICROAGGRESSIONS BY PROVIDERS & MATERNAL DEATH STATISTICS**
|Our Future||Our Reality||Advocacy & Action Items|
|“I have the right to be listened to and heard.”||Research shows that white providers spend less time and use more patriarchal and dominating language with Black patients (Institute of Medicine, 2003). Health care workers are twice as likely to ignore, refuse a request for help, or fail to respond to requests for help in a reasonable amount of time for birthing patients of color (Black, Indigenous, Asian, and Pacific Islander) as compared to white birthing patients (Vedam, Stoll, Taiwo et al., 2019). Implicit bias training alone is shown to have a limited, short-term impact (Pritlove, Juando-Prats, Ala-Leppilampi et al., 2019)||
· Advocate for every birthing person of color to have access to affordable midwifery and/or doula care.
· Support programs that raise funds for Black- and Indigenous-owned birthing centers, like Birth Center Equity.
· Contribute to scholarships and mentoring for Black doulas and birth workers including nurses, midwives, and medical students under programs like the National Black Nurses Association, National Black Midwives Alliance, Melanated Midwives and National Association to Advance Black Birth (NAABB), and the National Medical Association.
· Advocate for anti-racism trainings for providers like Dignity in Pregnancy and Childbirth.
· Bystanders speak up when patients are ignored or have their symptoms dismissed.
· Support systemic changes across health care such as increased funding for clinics in neighborhoods of color, more time per patient, and more support for providers to avoid overwhelm and burnout.
· Submit an Irth App review of every birth and encourage and support clients to submit reviews.
|“I have the right to receive care from providers that share my cultural background.”||A large study shows that patient outcomes are better when matched with providers of the same race (Greenwood, Hardeman, Huang at al., 2020). Meanwhile, most obstetricians, pediatricians, midwives, and labor and delivery nurses are white. There is a long history of discriminatory factors and anti-Black racism that led to fewer Black students being admitted to nursing, midwifery, and medical schools.||
· Contribute to scholarships and mentoring for Black nurses, midwives, and medical students under programs like the National Black Nurses Association, National Black Midwives Alliance, Melanated Midwives and National Association to Advance Black Birth (NAABB), and the National Medical Association.
· Assess medical training programs and labor and delivery units for aspects of white supremacy culture or unequal treatment that make it difficult or impossible to retain Black students and staff.
· Support workplace policies that allow employees to bring their full, authentic selves to work.
· Update medical training curricula and in-service trainings to debunk racist myths such as Black people feeling less pain or that race or pelvic shapes determine someone’s likelihood of a successful vaginal birth after cesarean
· Have a zero-tolerance policy for racist comments about patients/staff or racial microaggressions toward patients/staff.
· Advocate for the AMA and ACOG to offer reparations for their role in the elimination of Grand midwives and closure of Black-led medical schools under the Flexner Report.
|“I have the right to a doula or other professional support person.”||In a recent study, only 15% of Black birthing people who gave birth in California had support from a doula. However, 66% want support from a doula at a future birth (Sakala, Declercq, Turon et al., 2018).||
· Fund and support community-based and full-spectrum doula training programs like Birthing Advocacy Doula Trainings with Sabia Wade.
· Oppose legislation that requires certification from specific doula training organizations, unless they are diverse and inclusive, and truly contributing to cultural connection, access and competencies.
· White doulas may inform potential clients of local or virtual Black, Brown, Indigenous and intersectional doulas and free doula text services such as JustBirth Space when needed/appropriate (i.e. “I wanted to let you know that there is a strong community of Black doulas also available to you, either in-person or online. I’d like to pass along their contact info so that you can connect with them to learn more, if you’d like.”)
|“I have the right to early postpartum visits and individualized postpartum care.”||
77% of maternal deaths happen in the postpartum period after giving birth, and 66% of these deaths are considered preventable (CDC, 2019). The World Health Organization recommends immediate and frequent postpartum monitoring, but up until 2018, ACOG only endorsed one postpartum visit at 6 weeks. Now they say the first postpartum visit should take place within 3 weeks, but few providers offer this as standard care. Home postpartum visits are rare in the U.S., even though many European countries provide home postpartum visits as part of standard care.
· Advocate for every birthing person of color to have access to a postpartum doula, home nursing and lactation, and mental health visits (with providers of color, if preferred) and extra healing support to tend to any trauma from pregnancy or birth.
· Encourage patients to develop a postpartum plan that incorporates their own cultural traditions.
· Refer your clients to programs that offer additional virtual/wraparound support through pregnancy and postpartum, like Mahmee.com.
· Educate your clients about programs that deliver nourishing food to postpartum parents, like Hola Postpartum. Bring food to your postpartum friends and clients!
· Spread the word that home birth midwives can provide early postpartum care at home, even if they did not attend the birth itself.
· Ensure that your local MMRC has representation from BIPOC community members and active birth professionals working in the communities at highest risk. Inquire about ways that meetings can be structured to be more accessible to community members and frontline birth workers, and that their time and expertise shared at meetings can be fairly compensated. Reach out to your local committee for any recent reports, like the Minnesota Mortality Review Report, and use their data and recommendations in your advocacy.
|“I have the right to choose how I want to nourish my child and to have my choice be supported.”||Most (68% of Irth App respondents) said that baby formula was given in the hospital against their wishes. Only 73% of Black birthing people ever initiate breastfeeding, as compared to 84% of white birthing people, and after six months, only 28% of Black parents are still breastfeeding,compared to 45% white parents and 46% Latinx parents (CDC, 2019).||
· Advocate for every birthing person of color to have access to a lactation consultant (of color, if preferred) who will support whatever their wishes are regarding infant feeding.
· Support programs that provide free lactation education and support for communities of color, such as the Chocolate Milk Café. and JustBirth Space as a text warmline for lactation questions.
· Advocate for every postpartum person to have access to paid perinatal leave, postpartum support, healing, rest, and nourishing foods to support their recovery and milk supply.
· End the formula shortage. Understand the connections between infant formula feeding, systemic racism, and race-targeted marketing.
· Integrate lactation training like the B.L.A.C.K. Course developed by Ngozi Tibbs (featured in EBB Podcast Episode #100) and others into nursing, midwifery, and medical school curricula.
· Fund scholarships for Black and Indigenous lactation specialists in your community.
· Celebrate Black Breastfeeding Week in all health centers and community spaces with education and support, while also warmly accepting all ways that parents choose to feed their children.
|“I have the right to restorative justice and mediation to address obstetric violence, neglect, or other injustices.”||It is difficult to file a hospital complaint, and you are unlikely to receive a response or change hospital policy. State licensing boards are also unlikely to respond to complaints about specific providers.||
· Submit an Irth App review of every birth and encourage and support clients to submit reviews.
· Use social media to share information and mobilize support, protection, and healing.
· Birth workers and community organizations can partner with hospitals to discuss how to address harm using restorative and transformative justice principles, mediation or circle process models, and more transparent feedback methods.
· Advocate for your local maternal mortality review committee to include restorative and transformative justice, mediation and accountability processes and reparations as a part of their official recommendations and reports.
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.
Reclaiming the Mothers of Gynecology
In August 2017, four young activists from the group, Black Youth Project 100 , staged a visual protest that would mark a turning point in how we remember the contributions of enslaved Black women to health care. The young activists dressed up in “bloodied” hospital gowns and stood in front of a New York City statue of the so-called “Father of Gynecology,” J. Marion Sims. This statue celebrated the Alabama doctor who, like many “slave physicians” of his generation, legally and experimentally operated on enslaved women without anesthesia, leading to the development of the speculum, fistula repair surgeries, and other early gynecological and obstetric procedures. The Black Youth Project 100’s powerful photo went viral, sparked nationwide conversations, and led to the removal of the statue from Central Park in April 2018, by a unanimous vote from New York City’s Public Design Commission.
In Montgomery, Alabama, as a response to another statue of Dr. Sims nearby, visual artist Michelle Browder created a larger than life, 15-foot-tall monument in honor of the three women who Dr. Sims experimented on–Anarcha, Betsey, and Lucy–honored as the Mothers of Gynecology. The three statues were made of donated scrap metal, with African beads around their neck and a speculum, like a tiara, resting on the head of Betsey. Words like “respect” and “resilience,” and names like “Angela Davis” and “Serena Williams” are welded to their metal bodies. Browder dedicated the public monument to every mother who has ever lost a child. She has invited birth professionals from around the country to visit during annual conferences on Black maternal health to change the narrative on medical racism and racial health inequities.
Pause, breathe, and notice your body’s response.
Reclaiming Traditional Midwifery
There are endless examples of phenomenal Black traditional midwives we could include here! This section features the history of Black Grand Midwives and the stories of certain elders and ancestors based on their historical contributions to the U.S. Black midwifery community. We also acknowledge that historically, childbirth was supported by an entire circle of birth workers and caregivers, without today’s professional and legal divides across certifications, midwives, doulas, and other perinatal professionals. We honor all the providers who practice in the legacy and original scope of traditional midwifery.
Later, In Part 3: Equity Tools, we will take a more current look at visionary Black birth workers making waves today, including Jennie Joseph of Commonsense Childbirth in Florida and TIME “Women of the Year”, Okunsola Amadou, Founder of Jamaa Birth Village in Missouri, Ravae Sinclair, first Black President of DONA International and more. If you would like to add to our list, visit the Birth Justice page on the Evidence Based Birth® website or email email@example.com.
Black Grand Midwives (as opposed to a more diminutive term, “Granny Midwives”) not only caught babies, but were leaders, pillars, and overall healers in their communities, particularly in the U.S. South. Black midwives delivered most babies (both Black and white) in the South, at home, and up until the 1930s. Around the time when birth started to move from homes into hospitals, these midwives were almost entirely eradicated by smear campaigns led by doctors and the American Medical Association. “The Midwife Problem” was discussed openly in highly regarded medical journals like JAMA, where respected physicians called midwives “dirty,” blamed them for infant deaths, and claimed that “great danger lies in the possibility of attempting to educate the midwife. If she once becomes a fixed element in our social and economic system… we may never be able to get rid of her” (Charles Ziegler, MD 1913).
The Sheppard-Towner Maternity and Infancy Protection Act of 1921 introduced registration and licensing requirements for midwives and shifted the profession away from cultural and spiritual traditions that enslaved African midwives brought to the United States. Instead, new laws and policies forced midwives into a sanitation and biomedical model that prioritized cleanliness over touch and connection. Many birth workers of color now attend additional trainings such as Birth Mama classes with Mama Pilar Ma’at, Layla B’s Nafsa Project School, or Raeanne Madison’s Postpartum Healing Lodge to reclaim global traditional midwifery traditions that were lost, including womb massage and bodywork, “closing” the bones traditions, nutrition and herbs, community support, energy work, spirituality and ritual as essential parts of birth work.
Several well-loved Grand Midwives were celebrated in films, theatrical plays, books and autobiographies, and memorial libraries that help us remember their legacies today. Mary Cole was featured in the 1953 Georgia Public Health film All My Babies , and Margaret Charles Smith is the author of Listen to Me Good: The Life Story of an Alabama Midwife . Gladys Milton was trained by two physicians in order to receive her midwife license in 1959, and went on to establish the first birth center in Walton County, Florida (now called the Milton Memorial Birthing Center ). Her story and courageous fight with the state of Florida to maintain her midwifery license through the 1980s was captured in a play, documentaries, and the book, Enduring Women, and in 1994, she was inducted into the Florida Women’s Hall of Fame.
Through the COVID-19 pandemic, the U.S. Black midwifery community deeply grieved the loss of several elder midwives who were master educators, activists, and community organizers. Nonkululeko Tyehemba not only attended births, she also founded the Harlem Birth Action Committee, educated parents and trained doulas, and was among the early local promoters of the “postpartum visit.” She advocated for a USPS stamp to honor the Black Grand Midwife and worked alongside midwives in Somalia. Claudia Booker was considered a legend of her time, as a Washington DC-based lawyer, judge, and President Carter staffer-turned-midwife and well-loved public speaker on birth justice. Mama Claudia studied at The Farm with Ina May Gaskin, served as faculty or guest lecturer at several universities, and used her platform to challenge doula, midwifery, and breastfeeding programs to offer scholarships to Black birth workers.
For Mama Nonkululeko, Mama Claudia, Mama Afua Hassan of The Birthing Place (https://www.thebirthingplace.com/) and featured on EBB Podcast Episode #65, Mama Nasrah of Birthing Stronger Communities, and more, we remember that death is not the end. We celebrate their legacies and memories, we give thanks for all the birth workers they taught along the way, and we continue to heed their words, wisdom, and carry forward their work and pass the torch.
Shafia Monroe of SMC Full Circle Doula Training started out as one of the only active Black midwives in Boston, and over decades, has trained thousands of doulas and hosted gatherings of birth workers to teach the traditions of Black cultural birthing and healing. (You can hear more of her story in EBB Podcast #152.) In 2022, Mama Shafia organized the Alabama Black Midwives Conference to celebrate the legalization of midwifery in a state with some of the highest rates of maternal and infant mortality and lowest rates of midwifery and prenatal care. The conference opened with a procession of Elder Midwives and included drumming, dancing, prayer, and sharing songs that have been sung by Black Midwives and healers for generations.
The song listed below was sung joyfully at the Alabama Black Midwives Conference, as a part of a long lineage of singing songs together as midwives. It was originally gifted to the International Center for Traditional Childbearing (ICTC) by Byllye Avery, keynote speaker at the 1st Black Midwives and Healers Conference in October 2002 in Portland, Oregon. Since then, it is said to have been sung by midwives, doulas, and healers from all over the world, and we were given permission to share its lyrics here:
I love being a Midwife. Deep down in my soul.
I love being a Midwife. Deep down in my soul.
I said, deep, deep. I said down, down. Deep down in my soul!
I said, deep, deep. I said down, down. Deep down in my soul!
I said, deep, deep. I said down, down. Deep down in my soul!
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.
Acts of Resistance Against Tragedy and Fear
“Aftershock” is a new documentary featuring the behind-the-scenes stories of Shamony Gibson, Amber Isaac Rose, and other women of color who have died in childbirth. Their partners and family members speak of turning their “pain into purpose,” and taking to the streets and screens to advocate for Black maternal health. Viewers witness tender moments with these women before they died, including home videos and stories from now single fathers who are balancing raising young children, while grieving their partners, attending protests, giving talks, and connecting with other men around the country who also lost their partners in childbirth. The film features poetic storytelling and education on the reasons behind the Black maternal health crisis and offers a glimpse into some of the most powerful solutions – midwives, birth centers, and doulas. The film recently premiered at the Sundance Film Festival and now is available for streaming on Hulu.
Charles Johnson (briefly featured in the film above) launched a landmark civil rights lawsuit against Cedars-Sinai Medical Center in Los Angeles, where his wife, Kira Johnson, passed away hours after giving birth to their son, Langston. The suit accuses the hospital of racism over the poor management of Kira’s care after a cesarean section, during which Charles was told by a nurse that his wife was “not a priority.” Charles had noticed her catheter filling with blood and alerted her doctor, who ordered a “surgical emergency” CT scan that was never performed, according to the lawsuits. Over ten hours later, when Kira was finally brought to surgery, she had 3 liters of blood in her abdomen and died from hemorrhagic shock from blood loss.
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.
Black Visionaries in Birth Technology & Innovation
We’d also like to challenge a common misconception that Black people are not visionary or inventive in the realms of technology, science and medicine. To the contrary, historians document that some of the earliest iron tools were developed in Sub-Saharan Africa, and that the first successful Cesarean section was developed by doctors in Uganda. Long before germ theory was introduced in Europe, this Ugandan technique included using banana wine as sedative and sanitizer to clean the incision, and was later brought to Europe and named for Julius Caesar as we know it today. (You may have heard stories that Julius Caesar was born through an incision in his mother’s abdomen, but the U.S. National Library of Medicine shows conflicting information and suggests this is unlikely.)
Records show that in 1706 in Boston, an African man named Onesimus (original name unknown) taught his community’s technique for smallpox vaccination. This method, which parents on the African continent had used to protect their children from high rates of mortality with smallpox—was to scrape the pus of a smallpox victim into each child’s arm with a thorn. Onesimus’ “master” went on to survey Africans across Boston, who all told him of their own childhood vaccination stories. The white man wrote to the Royal Society of London about the method, acknowledging that he learned it first “from my Negro-man Onesimus, who is a pretty Intelligent Fellow.”
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.
Irth App: Holding Hospitals Accountable
The app is called Irth (think: earth!) and named for Birth, but they dropped the “B” for “Bias.” Irth is designed as a Yelp-like space for Black mothers and birthing people to rate their doctors (of all backgrounds). These ratings and commentary can then be used by other Black families to inform their choices.
Despite over two decades of research on racial health disparities, little change has been made in hospitals to improve care specifically for birthing people of color. Now, with direct hospital data in hand, the Irth Team has been able to build influential relationships with hospitals and take their advocacy and demands for equity to the next level!
Founder Kimberly Seals Allers is a journalist and former senior editor at Essence, five-time author, femtech founder and maternal health advocate. Allers tells the story of having her first child, when she “asked white co-workers and friends for recommendations, read all the “Best of” lists for hospitals, and was excited to deliver at a highly ranked institution. Instead, [she] left feeling dismissed, disrespected, and traumatized. Exactly opposite to what [her] white peers had experienced.” Years later, she began learning coding with her son, and created Irth as a way for Black and Brown birthing people to have a platform to share authentic stories of their providers and birthing experiences, and to suggest to others where to receive good care.
If you are a Black doula, midwife, or person who recently gave birth, please consider taking 15 minutes to complete a review of your experience – good or bad – on the Irth App! The more reviews that are collected, the more power this project will have to hold hospitals accountable. Doulas can add this as a standard part of each postpartum visit, to sit down with your client and talk/type through the Irth App review as a way of debriefing the birth experience, in a way that will impact future generations of Black birthing people and families.
Irth App submissions reveal these most common complaints (as shared on EBB Podcast Episode #220):
- Requests for help being refused or ignored
- Patients scolded, yelled at, or threatened
- Pain levels being dismissed
- Violations of physical privacy (i.e. “knock and enter” as standard practice)
- Inductions of labor for unknown reason
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: Comprehensive pregnancy & postpartum support, all in one place
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: A Free Text Warmline for Doulas and Lactation Specialists
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:
- TextConnect: Immediate answers to any questions about pregnancy or lactation.
- WeConnect: Phone or video support for more in-depth prenatal or postpartum care.
- 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.
Using Social Media for Exposing and Organizing
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
Part 3: Evidence Based Equity Tools - Table of Contents
- Part 3: EVIDENCE BASED EQUITY TOOLS
- The Evidence Based Equity Triad
- #1: The Midwifery Model of Care
- #2: Community-Based Doulas
- #3: Reparations and Transformative Justice
- ADDITIONAL EQUITY TOOLS
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:
- The Midwifery Model of Care
- Community-Based, Full Spectrum Doulas
- Reparations and Transformative Justice
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!
The Research: Midwives reduce racial disparities and the risk of mistreatment in labor and birth. (To learn more, visit https://evidencebasedbirth.com/evidence-on-midwives/).
The Challenge: Midwives only attend 9% of births in the U.S., 87% of midwives are white, and there have been documented examples of white midwives making racist comments and causing harm toward Black, Brown, and Indigenous midwives and midwifery students. Research shows that patients have better outcomes when they share the same race as their providers, but midwives of color are not accessible to many families due to where they live, what level of income and health insurance they have, and if they have a high-risk pregnancy that requires care with an OB/GYN. The entire midwifery profession, including midwives of color, has also lost much of its original grounding in cultural and spiritual healing when legislatures removed and then reinstated midwifery licensure in states throughout the U.S.
The Possibility: We can support scholarship funds and changes in midwifery education and accreditation to train more midwives of color, advocate for all midwife types to be accessible across the U.S. (in both rural and urban areas), and learn from global models where the midwifery model of care and midwife-obstetrician collaborations are accessible even for high-risk pregnancies. Midwives of all backgrounds may need additional training, partnerships, or policy changes to truly reclaim cultural birthing traditions.
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
The Research: Doulas lower cesarean and preterm birth rates, increase breastfeeding rates, reduce racial disparities, improve birth outcomes and risk of mistreatment in labor/birth. For more information and references, visit https://ebbirth.com/doulas.
The Challenge: Doulas are only present at 6% of all births, and families of color may struggle to access doulas due to cost, location, and the time-intensive process of learning about, interviewing and hiring doulas. Community-based doulas face challenging work, secondary trauma, and low pay… and many burnout and leave the profession after just a few years. Recently, more Medicaid funding has been going to reimburse doulas, but the process of registering doulas is bottlenecking the funds. There are some concerning signs that the doula “registration” process may end up mimicking the licensing process that made midwifery majority-white. Advocacy for community-based doulas also requires opposing lengthy, expensive registration/licensing or requirements that would add barriers to entry and gatekeep the reimbursement process.
The Possibility: We can learn lessons from midwifery and other holistic care professions such as chiropractic, physical therapy, and massage on how licensure can change the profession for better or for worse—and advocate against legislative or institutional processes that interfere with true community-based support. We press for innovations in how we fund and reimburse doulas to keep the profession diverse, while also ensuring a livable wage and sustainable, empowering work.
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.
Table 2: Community-Based Doulas compared to Traditional Doulas
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.
By My Side Birth Support Program in NYC
In Brooklyn, New York City, the By My Side Birth Support Program originated from an idea by Gabriela Ammann, who matched doulas with existing Healthy Start clients to receive continuous labor support to improve their birth outcomes. Compared to overall outcomes, By My Side program participants had nearly half the rates of preterm birth (6.3 vs. 12.4%) and low birth weight (6.5 vs. 11.1%) — again showing that programs led by Black and Brown birth professionals can eliminate racial disparities.
Momma’s Village in North Carolina
When Angela Tatum Malloy became a lactation professional in Fayetteville, North Carolina, she received repeated inquiries about Black doulas in the area, but there were none. When she realized that no local doula trainings focused on Black birth – she created one! Momma’s Village now offers African-centered doula trainings and a collective of Black doulas to support Fayetteville families.
National Registries of Black Doulas
If you live in an area with few or no Black doulas, you can check national registries here and here to see if any nearby Black doulas are listed. Or, if you know of Black doulas that are not listed here, encourage them to sign up on a national registry for free! There are also many new online doula trainings available since 2020, led by Black, Brown, and Indigenous trainers (see our Getting Started Handout in Part 1 of this Anti-Racism series, available at ebbirth.com/antiracism), as well as Black-led national certification options such as the National Black Doulas Association founded by entrepreneur, writer and Oakland native, Tracie Collins.
A Large Collective of Black and Brown Doulas in Connecticut
Bridgeport, Connecticut is home to the largest collective of Black and Brown doulas and the largest Black-owned training organization of doulas in Connecticut. Led by SciHonor Devotion, the Earth’s Natural Touch Doulas call themselves “The Dada Zuri Sisterhood” (“dada zuri” means “beautiful sister” in Swahili), and they offer full-spectrum and interdisciplinary birth and postpartum care across 13 states. They also offer doula support for bereavement, loss, or grief, and host a free Mocha Milkshake Café gathering on Zoom on Saturday mornings, for anyone around the world!
A Prison Doula Program in Pennsylvania
In Pennsylvania, pregnant women who are incarcerated at State Correctional Institution (SCI) -Muncy can connect with a doula over bi-weekly visits and labor support as part of a new partnership between Genesis Birth Services, the Tuttleman Foundation, Department of Health, and Governor Tom Wolf and the First Lady. In the program announcement, Max Tuttleman of the Tuttleman Foundation explains why this program is important, saying:
“When an incarcerated woman gives birth, most of the time she’s alone, scared and without any support from her family to be by her side. In our minds, no woman and no one should ever have to feel that way when trying to bring a life into this world, no matter what mistakes they may or may have not made.”
The owner of Genesis Birth Services, Gerria Coffee, is also the President of the Pennsylvania Doula Commission, Equity Chair for the Pennsylvania Breastfeeding Coalition, and Advisory Board Member for the Healthy Start Center for Urban Breastfeeding. She is making waves as a doula, trainer, lactation counselor, and advocate for state funding and doulas as direct Medicaid providers to support high need populations like formerly/incarcerated parents as they transition back into their families and communities!
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:
- 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?
- 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?
- 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
The Research Says: We have data from Maternal Mortality Review Boards and lawsuits, although both these angles are high pressure and intense environments for community members and families. Many birth justice campaigns and programs work in the realm of political or democratic accountability, appealing to public opinion and naming the issue as a human rights violation, but few programs can offer incentives, consequences, carrots or sticks, on a legal or financial levels, to more strongly enforce and influence medical care.
The Caution: Traditional cultural wisdom suggests that an open conversation about healing and accountability is necessary, but fears of malpractice lawsuits make providers and hospitals often unwilling to admit fault, discuss cases, or offer apologies. Ironically, this leaves malpractice lawsuits as the only way for individuals to open an accountability process.
The Possibility: Is there another way to address and heal from past harm, beside lawsuits? How can we increase and strengthen accountability mechanisms that work on performance accountability and financial levels, such as offering incentives for reducing racial disparities, and true consequences for providers and institutions who cause consistent harm? We can learn from local and national police reform efforts, policy proposals, and accountability for “bad apples,” and carry lessons learned over into birth work. We can also learn from abolitionist models like transformative justice and criminal justice reform.
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:
- Performance Accountability
- Political / Democratic Accountability
- 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
- 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:
- Classroom instruction on health inequities, stereotypes, microaggressions, interracial provider-patient interactions, and racism.
- 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.
- 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.
Note: We at EBB also acknowledge that interracial exercises could be triggering for people of color whose vulnerability in sharing has been met with harm in the past by white people. These types of exchanges should be carefully facilitated and include clear and informed consent.
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.
Note: We recognize that use of the term “Reproductive Justice” can be co-opted by white researchers and advocates to capture the interest of progressive publications and funders, without giving due credit and attention to Black and Brown experts and leaders on the grassroots level. We include this section to explain the history of this term, with the expectation that it will not be used in performative ways, but in ways that build our collective solidarity and allyship.
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.
What’s the bottom line?
Voices from the margins to the mainstream
“We will not end white-body supremacy – or any form of human evil – by trying to tear it to pieces. Instead, we can offer people better ways to belong and better things to belong to.”
-Resmaa Menakem, Embodied Anti-Racism Educator and Author of My Grandmother’s Hands: Racialized Trauma and the Pathway to Mending Our Hearts and Bodies
As birth workers, we have seen the power of moving ideas into the mainstream. Over barely ten years, a “doula” went from being barely understood, to becoming a household concept for expecting parents. The creation of films like the Business of Being Born or Aftershock, or the annual Black Maternal Health Week, have all catapulted conversations about natural birth and the Black maternal health crisis into the living rooms of people around the United States-shifting our culture and ways we think about birth, and Black birth.
We started this journey with a request from birth workers on the front lines of protests in Minneapolis in 2020, to use our platform to educate on anti-racism research in birth work. But we quickly realized it takes more than research! It takes building new relationships. It takes moving ideas, conversations, and the voices of leaders from the margins and sidelines into the mainstream… until an entire generation sees and treats Black and Brown birthing people differently.
For us, the bottom line is – How can we move Black, Brown, and Indigenous voices, proven leaders, innovative programs, and sustainable accountability, funding, and legislation from the margins to the mainstream?
If you are a white ally/accomplice reading this:
If we asked you to think of one person of color whose visionary work in birth justice inspires and excites you most – who comes to mind?
Pause, breathe, and notice your body’s response.
Follow your intuition! If this person’s vision resonates with you, it likely resonates with others too! What would the world lose, if this vision never reached its full potential for no other reason than this person’s race? To help rebalance the scales, you can follow their lead, offer what support, skills, and resources you can (in a way that is sustainable for you), and do your part to help the ripples of their work expand and impact the next generation. If their vision deeply resonates with you, perhaps this vision is part of your purpose and calling in life, and this person is a part of your Soul Family – whether you know them personally or not! What if supporting this work felt less like a volunteer task or one-time project, but the start of a lifelong relationship that helps deepen your legacy and mark on the world.
Keep in mind that the evidence points to three major areas that we named the “Equity Triad,” because each of these factors helps to ground and stabilize each other. These three represent a powerful crossroads, where the birth justice strategies proposed by many Black and Brown birth visionaries, the types of care desired by Black and Brown families, and the evidence all converge into an evidence-based equity triad.
- Midwifery Model of Care
- Community-Based Doulas
- Reparations and Transformative Justice
If you are a community leader of color:
We are grateful for you! We honor your work exactly as it is. We also invite you to use your influence not only for change in your community, but to think BIG. How can you create a wave of support around you, so that the work becomes larger and more sustainable than if it were you alone? Thinking bigger also does not mean doing more work! We wish you enough teamwork, supportive and sustainable funding, and community helpers to be able to manifest your vision, even as you take time to rest, heal from your own traumas or grief (many of us are wounded healers!), enjoy your own families and freinds, and experience your own version of reproductive justice.
If you are a Black or Brown (current or future) birthing person:
The evidence recommends that you can buffer the potential effects of racism and chronic stress by offering yourself physical, emotional, and spiritual care. You can do this with mindful, trauma-informed practices that calm the nervous system, and activate your parasympathetic (“rest and digest”) state such as walks in nature, meditation, movement and dancing, holistic care services, and building up a strong community care team to help you carry your load – you don’t have to do it all alone! Kimberly Seals Allers has shared her concern about the “Strong Black Woman Syndrome” in U.S. Black culture, which is also named and supported by research (Giscombe, 2010).
Remember that individualism is a part of white supremacy culture, while many of our ancestors worked together, and made community decisions collectively, and shared their resources (Okun, 2021). Asking for help was not always considered a weakness! Doing less, taking breaks, and saying “no” sometimes, will make it possible to say “yes” to yourself, “yes” to your healing, and “yes” to joy which is also your birthright! We hope for culture change in the future, which begins with the culture inside each of us changing, too. In the famous words of Mahatma Gandhi, “You must be the change you wish to see in the world.”
It may be helpful to gently, mindfully educate yourself (or ask your partner, doula or care team) to stay aware of red flags for birth complications that are more common for Black, Brown or Indigenous birthing people, such as preeclampsia. Because one red flag for preeclampsia is persistent high blood pressure, you can buy a kit for around $20-30 and track your own blood pressure at home and during times when you are relaxed. If you get to know what your normal blood pressure is, it can be easier to advocate for yourself and know if you need urgent attention.
Find a provider you can really talk to, who has time for you, and who understands and believes you – think about looking for a doula, midwife, birth centers, or an OBGYN of color! SistaMidwifeDirectory.com is a great search directory for Black midwives and doulas. We also recommend reading this New York Times article as a guide for protecting your birth (note: this is written with cis-gendered language), listening to award-winning podcasts like Natal to learn more about having a baby while Black, or Birthright hosted by Kimberly Seals Allers, for intentionally positive birth stories to balance out all the fear and negativity that you may face as well.
For all our readers:
“From John Henrik Clarke, our notable Historian, Professor and Pan Africanist: ‘The events which transpired 5,000 years ago; five years ago or five minutes ago, have determined what will happen five minutes from now; five years from now or 5,000 years from now. All history is a current event. It symbolizes the timelessness which is expressed in the African concept that all time, the past, present and future, exists simultaneously in what has been referred to as the ‘eternal now.’”
~ Quote brought to our attention by Patricia Loftman, Black Elder Midwife in New York City
We can take precautions and educate ourselves, without taking on fear or shame. We can see how strategy is important; but urgency is based on fear and scarcity, arising from white supremacy culture (Okun, 2021). As advocates and birth workers, we think from the present, remember the past, and act for the future. This work is equally as much about each single conversation and teachable moment, as it is intergenerational, systems, and cultural change. We plant seeds by loving and amplifying each other, by standing up and protecting each other, and by allowing ourselves to be supported, protected and rest – allowing those of us with traumatized, exhausted, and hypervigilant nervous systems the rare opportunity to heal. We trust and know that the ripples of our actions will carry on far beyond ourselves, and far into the “eternal now.”
Years from now, when you are asked what you did to answer the call of this time, to respond to the grappling of this generation through pandemics, climate change, human rights, bodily autonomy, equity and liberation — What will you say? Where are you being called?
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We would like to extend our sincere gratitude to expert peer reviewers for this article, Dr. Sayida Peprah-Wilson, Licensed Clinical Psychologist, Doula, Cultural Competency Trainer and CEO of Diversity Uplifts, Inc, and Aimee Brill, Birth Justice Trainer, Advocate, and Co-Director of Village Birth International. We are also grateful for additional editing and feedback sent by Anna Bertone, MPH and Erin Wilson, MPH, as well as the substantial feedback sent to us during the open comment period by EBB Pro Members Candace Martin, RN, BSN, BA, Ravae Sinclair, JD, PBD (IPP), CLC, AdvCD (DONA), PCD (DONA), Denise Bolds, MSW, Adv.CD (DONA), CLC, CBE, and Michelle Gabriel-Caldwell, PhD, CD, CBE, LE. We would also like to thank Tyler Jean Dukes, PhD candidate, and Anna Bertone, MPH, for their assistance with the Black Tile project.
Personally, Ihotu would like to thank her teachers and mentors in birth work, bodywork, and research, including Elders Malidoma Some and Sobonfu Some, Koye Oyerinde, Aline Mukundwa, Dahada Ould El Joud, Les Roberts, Martine Jean-Baptiste, Patricia Loftman, Ekua Ansah-Samuels, Mario Drummonds, Nan Strauss, Rebecca Dekker, Cathy Calderon, Panquetzani Ticitl, Rosita Arvigo, Beth Townsend, Anne-Marie Wiley, Cat Wiley, Katinka Locascio, Simone Burgos, Gail Tully, Kimberly Hart and Cheo Torres. (Ihotu chose not to list her teachers’ specific credentials in order to equally honor lived experience, intuitive wisdom, and professional expertise.)
Rebecca would like to gratefully acknowledge the Black birth workers, researchers, midwives, and healers who have taught her so much, including: Jenna Hatcher, PhD, RN, Ngozi D. Tibbs, LCCE, IBCLC, Sayida Peprah-Wilson, PsyD, Charlotte Shilo-Godeau, LM, CPM, Stephanie Mitchell, DNP, CNM, Ihotu Ali, MPH, LMT, Doctoral student, Denise Bolds, MSW, Adv.CD (DONA), CLC, CBE; and Michelle Gabriel-Caldwell, PhD, CD, CBE, LE.
Both Ihotu and Rebecca would also like to name and acknowledge the grand midwives who have touched our lives before and after their transition: Mama Afua Hassan, Mama Claudia Booker, Mama Nasra, and Mama Nonkululeko Tyhemba.
Ta Nehisi Coates says, “Much of our country’s history is premised on forgetting, not remembering, certain things.” A land acknowledgment is a simple, powerful way of showing respect, and of correcting the stories and practices that erase the histories of the peoples who inhabited the land in which we live and work. We would like to respectfully acknowledge the original inhabitants of the land in which we live, and from which we worked as we wrote this article.
Rebecca and Ihotu respectfully acknowledge living on the traditional land of the Shawnee and Anishinaabe people, and we pay our respects to their spirits and elders, past and present. We also acknowledge that the lands on which we work from (also known as Kentucky and Minnesota) owe their prosperity, vitality, and beauty to the African peoples who were enslaved and brought to this land and held against their will for hundreds of years, and whose descendants were legally and forcibly barred from participating in public life until 1965. We pay respects to their spirits, to their ancestors and their descendants.
Truth and acknowledgment are critical to building mutual respect, and connection, across all barriers of heritage. This is just a beginning of an effort to acknowledge what has been buried and forgotten by some, by speaking the truth, loudly and prominently. Please join us in taking a moment of silence to breathe and consider the legacies of violence, displacement, migration, and settlement that have all brought us to where we are today.
Photo credit: Leilani Rogers Photography & Jennifer Mason Photography
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