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This Obstetrician Recommends Midwifery Care:
But Why are Midwives in Short Supply?

By Leslie Farrington, MD, Cofounder of Black Coalition for Safe Motherhood

In 2014 I learned about the worsening maternal mortality statistics in the US, and the racial disparities in maternal health, which could not be explained away by socioeconomic or medical risk factors. I decided a community-based solution was necessary because, as an African American Obstetrician, I had no expectation that my fellow Obstetricians would soon recognize how racism permeated our specialty and impacted the lives of birthing people, especially Black women.

Black Coalition for Safe Motherhood promotes the ACTT Curriculum for Black health care consumers to advocate for their rights to safe respectful medical services. ACTT stands for self-affirming and potentially lifesaving steps to take in the office, clinic, hospital, and especially on Labor & Delivery:

• Ask questions until you understand the answers.
• Claim Your space – Physical and Mental.
• Trust Your Body
• Tell Your story

If Black birthing people were cared for by Black Midwives and other birth workers like doulas, who listen to and support them, research shows they would have better outcomes and less traumatic experiences of care. And there would be little need to ACTT. But culturally congruent care is hard to find because of the lack of Black Midwives. And many women mistakenly believe that obstetrical care is safer than midwifery care.

Recently I learned how Obstetricians virtually eliminated the centuries old practice of Traditional Midwifery in North America and medicalized birth. The result has manifested over the last several decades in the rising c-section rates and, to an unknown extent, worsening maternal health statistics in the US, especially for Black and Indigenous birthing people. Most Obstetricians are not aware of the history of the specialty, and they do not see the obvious effects on the business of birthing. Even if they were aware, hospitals are too invested in the status quo to adopt the midwifery model of care. The fact that racism outside of obstetrics plays a large part in the Black Maternal Health Crisis does not diminish the impact of obstetric dominance and medicalization of birth.

The benefits of Midwifery are not well known in this country because 90% of births are attended by Obstetricians. In European nations most births are supported by midwives – with much lower rates of poor outcomes and at half the cost of US maternity care. Even though it is well known in the public health sector that Midwives Save Lives, we do not see hospitals rushing to reduce the profitable high intervention business of Obstetrics.

Public health experts, Black, Brown, and Indigenous reproductive justice scholars, activists, and birth workers, all can see that the emperor has no clothes on, but doctors and hospitals still see themselves as fully dressed. This is not surprising. After all, the statue of the “Father of Gynecology” J. Marian Sims was only recently removed from its Central Park location because his craft was developed on the bodies of enslaved women. Now the American College of Obstetricians and Gynecologists and the American Medical Association acknowledge their racist origins, policies, research, education, and mistreatment of non-white patients, and have developed strategic plans to increase equity, diversity, and inclusion, and eliminate racism in medicine.

But that’s not the same as recognizing that Obstetricians put Traditional Midwives (especially Black Midwives) out of business by slandering them and virtually outlawing them in the early 1900’s. By denigrating midwifery care, pathologizing the natural process of birth, and instilling fear of complications and pain, doctors persuaded women to give birth at the hospital under their care. By touting the benefits of anesthesia, forceps delivery, episiotomy, and promoting in-hospital birth, doctors and hospitals were able to capitalize on the new specialty.

Interventions of increasing risk and complexity, and their routine use – without proof of benefits for the 80% of birthing people who are low risk – have caused harm not just because of their invasive nature, but because the birthing person is subjected to various forms of persuasion and coercion (without informed consent) to do what doctors believe is best for them and their babies. Many of the practices employed on Labor & Delivery interfere with the natural process of birth. When patients ask to avoid those interventions (which often make life easier for the staff or more money for the hospital) they are told they are not allowed to do what they want for their labor and birth. In a 2019 survey of women who gave birth in US hospitals 28% reported mistreatment. Black people report discrimination in about one third of their medical encounters.

Hospitals and doctors are comfortable placing blame on patients for poor outcomes and avoid transparency about those outcomes. It may take decades for Obstetricians to embrace the midwifery model of care, collaborate with midwives, support out of hospital birthing options, and listen mindfully to all the people they serve. That is why it is up to the consumers of maternity services and birth justice advocates, like Black Mamas Matter Alliance, to light the way forward. In the meantime, while pushing for improvement, there is the option to ACTT.

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OV is Mistreatment or Disrespect by medical personnel during Labor or Birth

The Giving Voice to Mothers Study 2700 US Women Surveyed

One in 6 (17%) US women surveyed reported mistreatment giving birth.  About 27% of women of color with lower socio-economic status report mistreatment including “…loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help.”

“Black women, Hispanic women, Asian, and Indigenous women were twice as likely as White women to report that a health care provider ignored them, refused their request for help, or failed to respond to requests for help in a reasonable amount of time”

OV ranges from verbal disrespect to physical assault. All are traumatic for birthing people and may result in short term and long term mental and physical health impacts on the mother/infant dyad.

Joking about pain and loss of autonomy and dignity

Paternalism – you are Allowed or Not Allowed, ignoring a birth plan

Dismiss or Ignore patient reports of pain or other symptoms

Microaggressions and Disrespect

Coercion – giving biased (not evidence based) information, threats of harm, calling Child Protective Services and threatening legal kidnapping

Procedures done without consent – vaginal exam, breaking bag of waters, episiotomies

Physical restraint and forced procedures = Assault and Battery!

Disrespect, Degradation, Assault when Giving Birth can cause PTSD and PPMD and can impact infant health.

Why is OV happening?

History of Obstetrics: founded in Sexism, Racism, Capitalism, Patriarchy, the pathologizing of Birth, and the virtual eradication of traditional African American Midwifery

Medical Training Pecking Order and Culture of Disrespect

“Disrespectful behavior threatens organizational culture and patient safety in multiple ways. A sense of privilege and status can lead physicians to treat nurses with disrespect, creating a barrier to the open communication and feedback that are essential for safe care. A sense of autonomy can underlie resistance to following safe practices, resulting in patient harm. Absence of respect undermines the teamwork needed to improve practice. Dismissive treatment of patients impairs communication and their engagement as partners in safe care.”

Doctor/Patient Power Differential and Ignorance of Human (Maternal) Rights

What Can Be Done to Avoid/Prevent OV?

Vet Maternity Services Early – learn about their policies and names of those in charge

Culturally Congruent Care, Midwifery, Community Birth (outside Hospital)

Learn about Pregnancy and Birth so you know what you need, value, prefer

Know Your Rights and Practice ACTTing

Bring a Doula, or well-informed partner, get names/titles of staff, post patients Bill of rights of the Hospital or the State

Create and post one page Birth Plan several copies.

Give and Expect Respect and Empathy – if not – Switch Nurse/Doctor

If OV does happen – Lawsuit rarely helps

Get Support, write complaint to CEO etc, Patient Advisory Council of the Hospital, Reviews – including on the Irth App. News Media or Social Media – Videotape or audiorecord.

White supremacist ideology has influenced scientific research from the 1700’s to the present. The evidence abounds in the subjects and topics “researched”, the language and images used, and the assumption that the norm is of European descent. Everyone else is racialized and characterized as biologically or genetically or socially less than.

Research from the white supremacy perspective informs theory and doctrine in all the helping disciplines. The policies of public health and social work departments, health systems, institutions of learning, and the training of professionals are thereby based on ideology which maintains white advantage and devalues people of color. The behaviors and practices of social workers, therapists, teachers, nurses, and physicians are influenced by the way they are trained to see and think about non-whites. From early childhood, mainstream culture ingrains racial bias in future helping professionals so that, between their upbringing and their training, these professionals have the potential to visit harm instead of help on the children they teach, the poor they are supposed to support, and the sick they are supposed to heal. They become instruments of ongoing oppression, despite their good intentions. They say Black children are behavior problems, Black people don’t have strong families, and Black patients are non-compliant, poor historians with low health literacy. There is little or no understanding of how US history – and present – perpetuates the disadvantage Black people have struggled with for centuries. And no attention has been paid to how we have excelled and overcome the obstacles of a society rigged against us.

Its time to flip the script and study the practices of the Black midwives – before modern obstetrics put them out of business. It’s time to cite African American academicians with culturally afro-centric, Black feminist, and human rights perspectives, and learn from education innovators of color. Its time to listen to Black women on committees and in the exam room, and not interrupt or dismiss them – disparaging their contributions, perspectives and symptoms. Changing the deeply embedded white supremacist mindset and behaviors in the helping professions will take study, guidance and life-long practice. Hence the need for consultation, training and long term follow-up from an organization or firm with years of experience in Dismantling Racism.

Americans who read The Unequal Distribution of Health in the Smithsonian Magazine may be shocked to learn that US women today are 50% more likely to die in childbirth than their mothers, and that our death rate is 3 to 5 times higher than European countries. They may have thought this was a tragedy only in the Black community and not a problem with obstetrical practice in the US. Most Americans also do not realize that we are the only country where 90% of births are attended by physicians instead of midwives.

To a retired Black Obstetrician, and a student of the history of Obstetrics and Midwifery, what is almost as concerning as the racism in obstetrics is the lack of attention to the failure of Obstetricians to critique their own management of maternity care.  There is a lack of awareness of what has transpired since the pathologizing of pregnancy and birth, and the virtual elimination of midwifery practice in the US one hundred years ago. Yes, Black women are mistreated more than whites when accessing healthcare and we need culturally congruent and community-based care, but all women are at risk for mistreatment and harm, and the majority of those who die or suffer complications of pregnancy are white women. If doctors were faced with the clear connection between their interventions, patriarchy, and racism, and the rising maternal death rates of all mothers in the US, might they begin to employ the solutions advised by Black Midwives and Birth Justice Activists who are leading the charge to transform hospital based obstetrics to respectful maternity care?

Let us spotlight the flawed obstetrical experiment of medicalization of what is for 85% of birthing people a natural, powerful, joyful, and nonmedical life experience. Let us shine a light on rising c-section rates, labor inductions, traumatic births, and postpartum depression. Let us publicize the surveys of women which report verbal and physical abuse (known as obstetric violence) when giving birth in the hospital, especially when they try to assert their rights to bodily autonomy. This is an American problem, a lack of accountability and oversight of our medical and maternity care industry.

 

When we only focus on the racism in medicine and call it a problem for Black people, we allow doctors and hospitals to deny their complicity in perpetuating our dismal maternal mortality and severe morbidity statistics. That’s because most white Americans in the medical professions are in denial about their own bias, and they still believe that Black people are to blame for poor health outcomes. Doctors believe they are the best trained and educated to care for women, and midwives and out of hospital birth are the lesser options. Our statistics and studies of Midwifery care show otherwise. The American College of Obstetricians and Gynecologists (ACOG) has recently begun to change their guidelines to lessen obstetric intervention in order to reduce c-section rates, but they have no means to change the long held belief of Obstetricians in Active Management of Labor. ACOG also has a strategic plan to address racism, but it can not change the power differential which doctors cling to and the biases they deny.

Let’s call attention to Doctors’ and Hospitals’ controlling policies and procedures, along with the patriarchy and racism embedded therein. We can shift the narrative and revisit the safer and more supportive option for low-risk mothers – the traditional midwifery model of care which has served human beings for millennia. We can reduce the obstacles faced by people of color to a career in midwifery and establishment of birthing centers. Midwifery works for the rest of the world so why not the US? Let’s end Obstetric Supremacy.

Spotlight on Racism in Medicine during a Pandemic – We have the Solutions

On December 20 Dr. Susan Moore, a Black physician specializing in Family Medicine and Geriatrics, died from complications of Covid-19. Dr. Moore’s story is well known because it was posted on Facebook and viewed thousands of times. She videotaped herself in her hospital bed testifying to the mistreatment she was experiencing and stating that “If I was white I wouldn’t have to go through that.” Dr. Moore was discharged from that hospital on December 7^thand readmitted to another hospital 12 hours later with a spiking fever and dropping blood pressure. She is not the only Black person in 2020 to post their report of mistreatment on social media and die soon after. During the last two trimesters of her pregnancy, graduate student Amber Rose Isaac’s concerns were not heard by her doctors in telemedicine visits, and they would not see her in-person. Amber was at risk for complications due to an abnormality in her blood, detected in February, but not addressed. On April 17 Amber tweeted her frustration in dealing with “incompetent doctors” for two trimesters. She died 4 days later during the birth of her son.

Since the killing of George Floyd, viral videos of verbal and physical attacks on people of color by white people – on the streets, in coffee shops, parks, and classrooms – have made racism in our society plainly visible to many of those who were previously in denial. Whether perpetrated by police, or private citizens, or those in the “helping” professions, racial discrimination is coming under a spotlight. The exposure has not stopped the attacks, however. Reversing 400 years of white supremacist indoctrination will take much more than giving media attention to the devaluation of Black lives.

Now the spotlight is shining on racism in the medical-industrial complex. There are the videos and tweets. There are the news stories about the disproportionate impact of Covid-19 on Black and Brown and Native people. There are the proclamations by departments of health and medical professional organizations that racism is a public health emergency. Unfortunately, none of these alarms are likely to change the racially biased behavior at the patient’s bedside, or racism in medical education and research, and in the delivery of medical and maternity services. Black researchers, midwives, doctors, and doulas have solutions. Shining a spotlight on them may increase the chances of substantive and meaningful change. Here are just a few of many promising maternal health initiatives to amplify Black mother’s voices and improve their care.

SACRED Birth in the time of Covid-19, the first of its kind, is a Black women-led quality improvement research study, designed for and with Black mothers and birthing people who share their patient experiences of care in hospital settings during labor, birth, and postpartum in six key areas: Safety, Autonomy, Communication, Racism, Empathy, and Dignity. Led by Karen A. Scott, MD, MPH, FACOG, Associate Professor and Applied Epidemiologist at the University of California San Francisco, SACRED Birth aims to validate the first ever Patient Reported Experience Measure of OBstetric racism©, also known as the PREM-OB Scale™.  “The information gained from this novel survey instrument will help hospitals, health plans, scientists, funders, and the public better understand how racism and other forms of discrimination and neglect affect the way hospitals provide care, services, and support to Black mothers and birthing people during labor, birth, and postpartum.”

The National Perinatal Task Force (NPTF) is a consortium of community-based health centers or organizations who have committed to offering respectful, compassionate, and person-centered maternity care. Founded by Midwife Jennie Joseph of Orlando, Florida, NPTF is a grassroots movement of Perinatal Safe Spots (PSS) in areas where it is not safe or conducive to being pregnant or parenting young children. Each PSS is a resource for pregnant and postpartum people to get the physical, emotional, and informational support they need for their family’s health and wellbeing.

Midwife Jennie Joseph has shown how supportive and easy access prenatal care, the JJ Way, can eliminate racial disparities in prematurity and low birthweight. In 2020 she established Commonsense Childbirth School of Midwifery, the first Black owned and nationally accredited school of midwifery in the US. Eliminating racism will require increasing diversity in the maternity care workforce.

According to Dr. Lucian Leape, physician and professor at Harvard’s school of public health, “Disrespect is a threat to patient safety because it inhibits cooperation essential for teamwork, cuts off communication …and is devastating for patients.” Countering the medical culture of disrespect, Black Coalition for Safe Motherhood promotes healthcare advocacy of birthing people.  Participants in community workshops practice what to say and who to speak to when they are being rushed, disrespected, or dismissed as they seek help in medical settings. In so doing they assert their rights to respectful care, amplify their voices, and push back against racism in medicine.

These are just a few of the solutions developed by Black women with very limited resources compared to those of the medical-industrial complex, which gets 23% of it’s Medicaid income from maternity services and has the worst maternal mortality rates among wealthy nations. While in the US profit is prioritized over the health of mothers and babies, the Black community is leading the charge for respect, equity and quality improvement in maternity care.