A Case for Black Motherhood

How midwives and doulas are fighting to keep Black mothers alive by educating the public, pressuring lawmakers and filling in gaps in the health system

Kristen Johnson

On May 5, Miko Taliaferro went to the doctor at 31 weeks for a regularly scheduled appointment only to be told that she was three centimeters dilated and needed to go to the hospital immediately.

Taliaferro sat in the hospital room alone and scared, waiting for her boyfriend John to arrive.

She was in early active labor and doctors told her that they needed to stop it from happening or else she and her baby could be in danger. Taliaferro was given magnesium sulfate for ten hours - a drug used to prolong a pregnancy for up to two days and to prevent damage to a preterm baby’s organs, and her health was significantly impacted by the powerful drug.

Because of the side effects she was a fall risk, had hot flashes, tunnel vision, weakness and an extremely low blood pressure.

“John thought I was dying, and I was,” Taliferro said.

She stayed in the hospital for eight days before delivering her four-pound baby, Lallani Primrose who was sent to the NICU for more than two weeks. “In the moment, you’re just trying to get through it because it’s not about you anymore,” Taliaferro said. “Immediately after she was born I was just praying that she would cry.”

Taliaferro, 28, Maryland native, had just been promoted to a new position at Apple, Inc. and found herself sitting at her desk multiple times crying. She thought her emotions were due to the high demands of the new job, until she took a pregnancy test.

“That pink plus sign showed up so fast and I stuffed it back in the box and took a shower!” Taliaferro laughed through the phone.

Still, Taliaferro was excited to be welcoming a new baby and did all she could to be careful and healthy throughout her pregnancy even though she had a low-lying placenta - a condition that is known to cause severe bleeding during pregnancy.

She got “lucky” finding a practice in Maryland with a racially diverse group of doctors, something that was important to her as a Black woman.

“I’ve been in environments where the healthcare practice is mainly white individuals and some people aren’t treated as fairly,” Taliaferro said having had to switch doctors who weren’t listening to her.

“That's really frustrating and it’s hard to think that it’s because of your skin color or even because you’re a woman,” Taliaferro said.

Black women are three to four times more likely to die during childbirth compared to white and Hispanic women. According to the Centers for Disease Control and Prevention (CDC), from the years 2011 to 2014, 40 Black women died during childbirth for every 100,000 live births.

Despite the causes of death being similar to white and Hispanic women, Black women see higher rates of preeclampsia, hemorraging, cardiac events and racism and discrimination from medical providers.

The District of Columbia saw some of the highest rates of maternal deaths from 2014 and 2016 when nearly 75% of those deaths were of Black women, according to the D.C. Department of Health. Many of those women lived in Southeast, D.C., where the only two maternity wards have permanently closed. As a result, mothers are having to travel further for prenatal care and deal with overwhelmed doctors who may not always prioritize their treatment.

As the novel coronavirus has plagued the country and as recent killings of Black men and women have sparked uprisings, caregivers, lawmakers and advocates are calling for extensive reform in healthcare to address the systematic racism that forces Black mothers to look outside the traditional hospital ward for care to save themselves and their babies.

George Washington University Hospital, located in Northwest D.C., sees about 450,000 patients a year. The maternity ward offers a range of services accepts patients with Medicaid.

Jashia Pinkney is a midwife in D.C. and has centered her career around healthcare for Black women. She believes hospitals in the city are not doing enough to address the issues contributing to maternal mortality.

“I’ve seen people say ‘well, they’re probably not in pain’ when talking about Black women in the hospital,” Pinkney said. “It goes back to slavery when people would believe Black people were just tougher and could handle things differently.”

Pinkney is a native of P.G. County, Maryland, and works at George Washington University Hospital (GW). She was inspired by other Black midwives at GW to enroll in the school’s midwifery fellowship program to further her training.

Providers at GW work alongside midwives to deliver babies and care for mothers. Pinkney said even though the relationship between doctor and midwife is necessary, the two can clash when discussing forms of treatment for patients.

“Midwives and doctors just have different models of care,” Pinkney said. “We try to be less interventional and try to not rush the birth process but working in a hospital, you’re up against different things.”

Pinkney said sometimes she disagrees with different providers' practices. For example, some providers will induce a mother's labor by providing a medicine called pitocin or breaking their water, a process that is often necessary, according to
Lamaze.org.

“When we’re doing a vaginal exam and we see someone just say, ‘Okay, I’m doing a vaginal exam, you can let your legs open up,’ that drives my nerves,” Pinkney said. “I’m going to say, ‘would it be okay if I do the exam?’ Then, ‘would it be okay if I touch you?’ I am asking women their permission and being sure.”

Because of the hospital's busy maternity ward, Pinkney believes some women do not always get enough holistic care during labor and commends the support doulas can provide.

Midwives and doulas, according to Pinkney, can play an important role for mothers in addition to care from medical doctors.

“Birth is a very emotional experience,” Pinkney said. “Things happen during pregnancy in addition to women laboring to have the baby. Things happen to mothers after the baby is born. They need so much support. Midwives and doulas have been known to help decrease mortality rates.”

Mortality and morbidity rates in the District

A number of factors contribute to maternal mortality. Hemorrhages, high blood pressure and eclampsia, cardiovascular conditions, infection or sepsis are among the leading causes of death for pregnant women. The variations of factors change for all women but according to the CDC, more research is needed in order to understand and reduce pregnancy-related deaths.

The organization also counts the rates of severe maternal morbidity, or SMM. As defined by the CDC, SMM includes “the unexpected outcomes of labor and delivery that result in significant short or long term consequences to a woman’s health.”

Hospitals and health organizations use indicators to determine what issues women may struggle with while in labor or during their pregnancy that contribute to a “near miss” — surviving something complicated that might have killed them. In the United States, for every pregnancy-related death, about 70 women experience a near miss.

The SMM rate is usually much higher than the actual mortality rate. In 2014, the CDC determined that SMM affected more than 50,000 women in the U.S.

In the District, the Department of Health tracks the rate of maternal deaths and releases yearly studies. In their 2019 report on severe maternal morbidity in the city, during the years 2013-2017, there were 11 maternal deaths.

The victims were all non-Hispanic Black women — mostly residing in Ward 8, the city’s poorest ward.

In that same report, in just one year (2016-2017), the District determined 392 residents experienced one or more severe maternal morbidity indicators during a hospital delivery in the city. Some of these indicators were issues like aneurysms, acute renal failure, amniotic fluid embolism, cardiac arrest, heart failure and eclampsia.

“When we have the conversation about maternal deaths, we also have to be mindful of those opportunities where it came really close,” said Kristina Wint, the program manager for women’s health at the Association of Maternal and Child Health Programs (AMCHP) in D.C. “They’re often extremely traumatic to the woman who is experiencing them. Just imagine being at the most vulnerable moment of your life giving birth and then everything going crazy.”

In their 2018 Prenatal Health and Infant Mortality Report, the District’s health department also found that the majority of live-births in the District from 2010-2016 were by non-Hispanic Black mothers and the majority of women who received no prenatal care before having a baby were also Black mothers.

Two major hospitals in the District have closed their obstetrics units and maternity wards in 2017, leaving many poor women without close access to prenatal care. Providence Hospital and United Medical Center’s labor and delivery units serviced women, mostly Black and Latina, in Northeast and Southeast D.C. and were two of the few hospitals in the city that accepted Medicaid.

Now UMC, the only hospital east of the river (in South and Northeast D.C.), plans to close its doors in 2023, leaving all residents in the city’s poorest neighborhoods without a hospital.

Vanessa Hanible, a doula and activist in the DMV, has been fighting this issue for years. She’s signed petitions, attended hearings and meetings with community activists in the District to discuss midwifery and doula services and how the community can make home births and birthing centers more accessible.

“They still had people who were birthing and if someone needed care, quickly and they lived east of the river that was where they were going,” Hanible said.

Hanible said the issue of maternal health is not just about birth. “It’s about the prenatal experience and what we see is a lot of women being told that they’re not compliant in their prenatal care but part of that is travel.”

As Hanible explained it, if women have access to a car, travel is more doable than taking the bus or train to get to other hospitals in the city, according to Hanible. But without a car, just getting to the hospital can be even more strenuous.

The closest hospitals to neighborhoods east of the river are GW or Howard Hospital, which are both about a 20 minute drive from a Ward 8 neighborhood like Congress Heights without traffic or construction hindrances. By WMATA transit, the trip could take up to an hour with delays.

As a result, many Black women living Wards 7 and 8 do not get the prenatal care they need to properly address issues during pregnancy that often contribute to traumatic complications and deaths.

By car, the commute from neighborhoods in Ward 7 and 8 can vary. This map shows the distance across the Anacostia River from Congress Heights in Ward 8 to GWU Hospital in Ward 2 with light traffic.

A need for more resources

Doulas like Hanible and public health advocates like Wint want to see changes for Black mothers in the way they are cared for. To them, women should not be dying during childbirth when the factors that lead to their deaths and complications can be prevented. They believe midwifery should be the main form of obstetrical care for all women.

“What I’m seeing more of is more Black women and women of color looking more seriously at having a birth outside of the hospital,” Hanible said. “Just in general over the past few years, there has been more communication about maternal mortality and I think there has been a slow but steady increase looking more into doulas a variety of other types of care during their pregnancy.”

Hanible said she firmly believes in the need for funding and for lawmakers to recognize doulas as essential healthcare workers and for midwives to be able to have their own practices. State lawmakers in New York, Connecticut, Illinois, Texas, Massachusetts and Rhode Island have recently introduced legislation for doulas to be covered by Medicaid.

“We have to look at our legislature, we have to provide funding for Black midwives, we have to create scholarships and create more programs,” Hanible said. “We need to have Black providers in and out of the hospital and we need to be more proactive about updating new research to come out.”

Many lawmakers in Congress have also brought the issue of maternal mortality to the floors of the House and Senate. Rep. Ayanna Pressley, D-Mass., introduced the MOMMIES Act in 2019 alongside a similar bill introduced by Sen. Cory Booker, D-N.J., to expand health access for mothers across the country.

The Black Maternal Health Momnibus Act of 2020 was introduced by the Black Maternal Health Caucus to address the rate at which mothers are dying from pregnancy-related complications. Congresswomen Lauren Underwood, D-Ill., Alma Adams, D-N.C., Kamala Harris, D-Calif. and other members are backing the bill in hopes to “comprehensively address every dimension of the Black maternal health crisis in America.”

Still, Hanible wants more funding for doulas since they are not covered by most insurance like Medicaid. Many women, especially poor women, cannot afford one nor do that know about them.

Kelsey Ogenia and other doulas in D.C. are trying to change that.

Due to the changes of COVID-19, many hired doulas are not allowed in the hospital delivery rooms. Kelsey Ogenia now helps encourage and coach her clients virtually. (photo provided by Kelsey Ogenia)

“We are constantly pushing for policy changes and for grant funding for our doulas and trying to help other organizations set up doula programs that are more sustainable,” Ogenia said.

A native of Alabama, Ogenia is a senior doula at D.C. Birth Doulas, one of the doula centers in the city working to help advocate for maternal and child health. For Ogenia, doulas provide such a unique and essential service to mothers that enhances the overall quality of care.

“The funding of doulas is necessary to make them more accessible,” Ogenia said. “One of the barriers for a lot of women being able to have access to a doula is cost.”

She would like to help more women in the District and go into neighborhoods like those East of the River and care for mothers there.

“I still think there is a disconnect in information between white women and Black women and the use of doulas,” Ogenia said. “Part of my goals when I started working at D.C. Birth Doulas was doing more community outreach to women who look like me.”

Ogenia also criticized the flaws in the American healthcare system and models of care for mothers in the hospital. She said there needs to be changes in the way medical schools train physicians.

“We need to change text books because some textbooks still say ridiculous, racist things,” Ogenia said, indicating that many books still hold theories about Black people not feeling pain. She earned her master’s in public health from Boston University in 2017 and had some classes with soon-to-be doctors. “I think more people need to be empowered to check their bias.”

Impacts of medical racism

Implicit bias, as defined by the Kirwan Institute for the Study of Race and Ethnicity at the Ohio State University, refers to “the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.”

These biases worsen healthcare and treatment for the most vulnerable groups of people including immigrants, people with disabilities, LGBTQ people, Black people and people of color.

In April, Ogenia led the Black Maternal Health week at the practice and worked to inform the public about the mortality crisis among Black women. The practice itself has done extensive training to combat the issue of implicit bias in their field and advocate for health equity in the city.

“Implicit bias training should not be an elective in medical schools, it needs to be required,” Ogenia said. “The history of racism in medicine shouldn’t be an elective, it should be required.”

AMCHP’s Kristina Wint agrees with Ogenia that addressing the staunch racism and discrimination in the medical field will drastically impact the way women receive care.

“Implicit bias has become a bit of a buzz word but it’s a very real thing,” Wint said. “Some of our implicit biases are definitely racist but I think not wanting to listen is an implicit bias that some physicians have. Black and white, and everything in between.”

Wint, a Pittsburgh native, believes the entire framework of the way gynecology is taught in medical schools is also a problem.

“On our team we are really intentional in examining the historical context that has led us to where we are,” Wint said. “And I think historically the health community, especially in OB/GYN, the foundation that it is built on is one that exploits Black women. I’m thinking about J. Marion Sims and his experimentations on enslaved women without medication.”

J. Marion Sims is known as the “father of gynecology” for his pioneering work to develop procedures and techniques in women’s health during the 19th century.

Sims, however, owned slaves in the South and performed vaginal research and surgical procedures on enslaved Black women without anesthesia.

Vanessa Northington Gamble, a professor of medical humanities and American studies at George Washington University in D.C., said that Sims operated on 10 enslaved women from 1845 to 1849.

One of those women was a 17-year-old teenager named Anarcha who he performed about 30 surgeries on and it wasn’t until Sims “perfected” his surgical techniques on her that he began performing on white women with anesthesia.

Wint believes Sims’s inhumane practices and disregard for the pain of Black women could be one of the many reasons why racism hinders the fair treatment of women in reproductive healthcare.

At AMCHP, programs are created to address the immediate needs of mothers and children around the United States. They examine the ways in which moms and infants are neglected in health and make recommendations for how hospitals, medical professionals, and national organizations can work to prevent negative outcomes.

One of those initiatives that Wint is proud of is a partnership with the CDC titled Enhancing Reviews and Surveillance to Eliminate Maternal Mortality, or Erase MM. The program grants funding each state to implement a maternal mortality review committee to survey factors leading to maternal death, like the issue of discrimination.

Wint believes there should be more attention to hold racism accountable in hospitals. She is not the only one.

The Black Lives Matter movement

The recent protests in America have shined a light on the disparities in police force, prisons and healthcare and are pressuring elected officials to make immediate changes that will prioritize and protect all citizens.

Participants in Black Lives Matter protests want to see police officers held accountable for their racism and lack of transparency that has contributed to the deaths of countless Black people and people of color.

All the deaths of Black people at the hands of police and by medical professionals seem to have one thing in common: a blatant disregard for their lives and comfort.

Brittany Martin, a doula and mother of two living in Baltimore, referred to “obstetrical violence” when talking about her experience witnessing medical doctors ignore obvious signs of a patient’s discomfort.

She recalls a moment when she overheard a doctor tell her patient, “I’m sorry that was uncomfortable for you but we had to do it,” and feeling uneasy about the encounter.

“That’s where it gets tricky because it’s kind of being in like a weird place,” Martin said. “We’re holding space for these people and we wanna make them feel as comfortable as possible and be there for them, but then we also see them being mistreated. We see them ignored and disregarded.”

Pinkney can recall overhearing providers make statements about patients exaggerating their pain and statements about under or over medicating women in labor.

On June 5, Mayor Muriel Bowser authorized the street leading towards the White House to be painted in bold, yellow letters reading: Black Lives Matter. The plaza, a site of recent protests, was renamed on the same day.

Cheylaina Fultz, 33, destination wedding planner and entrepreneur, was pregnant with her second child when she was forced to leave a woman-owned medical practice to find a new OB/GYN just days before her due date.

“I could tell [the doctor] was trying to sway me to want to have a c-section again,” Fultz said. “She would say things like ‘well, one thing is for sure you’ll know what time you’ll have your baby and you’ll be out in 25 minutes, you won’t have to do all that laboring.’ I kept making it clear to her over and over that I was not having another c-section.”

Fultz experienced complications during her first pregnancy, laboring for nearly 48 hours with her doula before going to the hospital. As a result of a long labor, she had to deliver her baby boy via cesarean section and needed weeks to heal from the surgery.

For her second baby, Fultz, then 38-weeks pregnant, hoped to have a VBAC, a vaginal birth after cesarean section, but her doctor repeatedly dismissed her delivery preference and discomfort.

“I left that appointment thinking, ‘do I really want to stay at this practice if a doctor told me I should just leave if I'm not happy about something?’”

Since more reports of Black women dying in delivery rooms have surfaced, more people have begun to share their own stories of neglect and mistreatment in the hospital.

Serena Williams and Beyoncé were among those who shared their complications with pregnancy and medical care.

“I almost died after giving birth to my daughter, Olympia,” Serena Williams wrote in a 2018 editorial for CNN.

In a Vogue interview that same year, Williams also revealed that her daughter, Olympia Ohanian, Jr., was born via an emergency c-section and for six days after the delivery Williams fought for her life. She alerted a nurse about her shortness of breath and history of blood clots but the response was less than immediate and Williams found herself begging for help.

Vogue contributor Rob Haskell wrote:

“But this was just the first chapter of a six-day drama. Her fresh C-section wound popped open from the intense coughing spells caused by the pulmonary embolism, and when she returned to surgery, they found that a large hematoma had flooded her abdomen, the result of a medical catch-22 in which the potentially lifesaving blood thinner caused hemorrhaging at the site of her C-section. She returned yet again to the OR to have a filter inserted into a major vein, in order to prevent more clots from dislodging and traveling into her lungs. Serena came home a week later only to find that the night nurse had fallen through, and she spent the first six weeks of motherhood unable to get out of bed.”

A hope for midwives and doulas

Jashia Pinkney was inspired to create She Births from Within, an organization that helps empower women to feel confident in their womanhood and motherhood by providing support and resources for themselves and their families.

She created the organization partly because of her love for community work. The other inspiration was her effort to save mothers and their children.

“I wanted to focus on educating Black women and I wasn’t able to do as much community work at the hospital,” Pinkney said. “My model is that I help women to birth spiritually and naturally. Of course as a midwife I help women birth their babies, but I also try to empower women in general, to birth their dreams, goals, whatever you want.”

Pinkney refers to herself as a "millennial midwife" and hosts a podcast titled "Birth-ish," where Black women are invited to speak about their experiences and encourage each other.

For as long as she can remember, Pinkney has always known she wanted to help women and work in healthcare. She had thoughts of becoming a doctor while in undergrad but found midwifery to be more promising.

“It’s natural, it’s holistic,” Pinkney said. “I just wanted to be more involved with the care that I was giving my patients.”

Upon graduating from the University of North Carolina at Charlotte, Pinkney was unsure about the type of nursing she wanted to explore. She volunteered with women’s shelters and worked as a home birth nurse assisting pediatric nurses during deliveries. Soon, she would work as a postpartum nurse for four years.

"Then I started worrying about maternal mortality and Black women dying at higher rates," Pinkney said. "I was like, well what can I do in my career and in my purpose to help Black women?”

Among the caregivers interviewed for this article, they all mentioned that midwifery and having a doula or companion during labor and delivery is part of Black culture.

“In the early 1900s, late 1800s, Black midwives, all midwives, were so skilled at providing care that even white women would go to them for healthcare in an era where children would die of many things and childbirth was dangerous, they [midwives] were seen as a safe option,” Wint said.

The origins of Black midwives can be traced back to the continent of Africa, where midwives not only delivered babies but holistically cared for mothers and their needs. Enslaved Black women still practiced midwifery and helped their enslavers deliver children as well.

There was a shift, however, and according to scholars and midwives like Shafia Monroe, in the early 1800s, many states around the country created laws that would restrict midwives from practicing. All midwives were systematically prohibited from properly performing until there were very few midwives left.

“I really believe that we need a shift to really focusing on midwifery care,” Wint said. “When we look at other nations and how they’re having better outcomes than we are. We spend more money on healthcare and they are using midwives way more. I really see that as an answer.”

The last few months of 2020 have revealed more disparities for Black people in healthcare. COVID-19 has claimed the lives of more than 120,000 people in the United States and more than 20,000 Black Americans have died from the virus.

Additionally, Black men and women are more likely to die at the hands of police officers. The deaths of Breonna Taylor, George Floyd, Tony McDade, Sean Reed, Ahmaud Aubrey have fueled the rage of many people across the country and calls for police reform and defunding have opened new conversations about white supremacy and how it operates in America.

There is a parallel between preventable Black deaths in the street and preventable Black deaths in the hospital. And caregivers in the medical world hope that, as the country wrestles with reforming systematic racism, Black mothers will be a focus too.

In the Nation’s capital, midwives and doulas want better for families.

They want more funding.

They want the elimination of racism in healthcare.

Most importantly, they want mothers to live long, healthy lives.

Ogenia, the doula fighting to protect moms in the hospital, has a simple plea.

“My hope is that we don’t forget Black women.”