Leseliey Welch and Indra Lusero are parents and birth justice advocates who are helping lead a movement to create community birth centers across the nation. To help address the maternal and infant mortality crisis, they’re realizing a vision where midwives are the leaders in care in a reclamation of the normal physiologic process of birth. They say birth centers provide racially and culturally reverent care founded in safety, love and trust.

“Imagine a world where birth is safe, sacred, loving and celebrated for everyone,” says Leseliey Welch. “Imagine giving birth with midwives in a community birth center designed in response to the dreams, hopes, and needs of the community it calls home.”

Welch is co-founder and CEO of Birth Detroit, the first midwifery-led birth center in Detroit, which is set to open in the spring of 2024. She shared her vision at a Bioneers conference:

“You walk through the door so happy to be able to receive care at a community birth center right in your neighborhood. You, your partner and your children are greeted by name, maybe even with warm hugs. You are asked how you are doing, and you can tell that the person asking genuinely cares. They offer you water, tea, snacks, and you settle into a cozy sofa. There are shelves of birth, nutrition, breastfeeding and parenting books for you to borrow, and a little toy nook in which your little ones can play. 

“In the examining room, you feel at home with the warm colors and cozy furniture. Your partner even feels they belong here too, with posters celebrating Black and Brown fathers and disabled, queer and trans bodies. Your midwife greets you, and you remember how relieved you felt the first time you met, knowing that they were from your community. They welcome your whole family to the visit. Your kids listen to the baby and see them on the ultrasound. Your midwife asks you about how you’ve been feeling physically and emotionally, what you’ve been eating and how much rest you’ve been getting. They talk with the whole family about ways to connect with the baby and how to support you. It’s unlike any medical care appointment you have ever had, and when it’s time to go, you almost don’t want to leave.

“When you go into labor, there’s no frantic rush to the hospital. Your partner calls the midwife, the midwife reminds you what active labor looks and feels like and how to know when it’s time to come into the birth center. Hours later, you’re on your way. You walk into your birth suite and breathe a sigh of relief. Your midwife is there, and they have prepared for your birth journey. You feel loved knowing you can labor where and how you feel called to. Your power playlist comes through the speakers while you move and sway and breathe. You walk some. You sit on the toilet for a time. (Y’all know that’s comfortable if you’ve had a baby.) And then you move to the birthing tub. 

“Your partner whispers reminders of your beauty, your strength, your power. A familiar scent wafts from the kitchen where family is warming food they prepared for you earlier. Your kids are playing in the living room of the birth center. And labor is hard work, yet your surroundings are soft and gentle. You feel seen, heard, honored and supported, letting go of any concerns that you can’t do this.

“You feel your baby’s head emerge. The midwife’s eyes are reassuring. You change positions at will, responding to the knowing in your body. The surges come with more intensity. You may burrow into your partner’s chest. The newest member of your family arrives Earth-side in this sacred container of love, and everyone and everything is forever changed.”

From Othering to Belonging

Leseliey Welch has long held this vision for community birth centers. She is co-founder and co-director of Birth Center Equity, a national initiative to help Black, Indigenous and people of color overcome the barriers to opening holistic birth centers in their communities — the most negatively impacted in the country’s maternal and infant mortality crisis.

As a Black mother of color and queer person, she knows from experience what a difference specific kinds of care can make – including making the difference between life and death.

“I am doing the work that both breaks and opens my heart,” says Welch. “I know the joy and grief of pregnancy and childbirth. I’ve had a preterm baby myself. I’ve spent time in the NICU with my baby myself. And I have grieved a loss. I have had a rainbow baby, born on their due date and barely made it to the hospital. And I’ve also been present with my family when my nephew was born and passed away the same day – born too small, too soon. At that time, I worked at the city health department in maternal child health, and I would later read his name on the list of infants we lost that year.

“I share that not to ground us in grief. I want us to center on vision, but I also want to honor the grief and loss that comes with our birth experiences. The visioning is joyful, but it can also sometimes feel painful when we know that our births were nothing like that vision. Every day, I work toward that vision because it’s the vision I wish my brother and sister-in-law had; it’s the vision that would be the reason my nephew is still here; and it’s the vision we all deserve.”

Indra Lusero is the founder and director of Elephant Circle, a Colorado-based organization that also works nationally on birth justice and reproductive rights. 

“About 22 years, having completed the childbirth preparation courses at the local hospital, I, nonetheless, knew that something was missing,” says Lusero. “I was not the gestational parent of my oldest son. We had already been through countless experiences of being othered and excluded from healthcare; we were told that we couldn’t have a family in this way; we couldn’t do this. So we were already at this place that people told us we couldn’t be.” 

Inspiration for the name Elephant Circle came from how elephants give birth in the wild. The whole herd circles around the laboring elephant. They stay for the duration — connected, emoting, supportive. At this sacred and vulnerable moment of emergence, the elephants form a circle of protection and defense. 

Lusero believes that’s what humans need to do too. 

As a queer Latinx person, Lusero’s experience reflects the kinds of judgment, bias and othering that queer, lesbian and gay couples routinely face in this profoundly intimate and vulnerable journey. 

“I had this sense that there was basically a soul missing from this care that we had been so far receiving,” says Lusero. “I didn’t know what to do about that fact, I just knew it. I ended up just asking people, ‘Isn’t there something else? I feel like there should be something else.’ Fortunately, I was connected with a woman who’s a midwife in the community. They met with my partner of the time and me for an hour, sharing with us this alternative vision, helping me feel like I was right, there is something more, something else here.

“At that time, my partner wasn’t able to make the leap mentally to planning for a home birth after having planned this whole gestation for a hospital birth. So this midwife agreed to be our doula and go into the hospital with us, undeniably and totally transforming that experience. I am 100% confident that it would have been totally different if we hadn’t made that connection.” 

The Intersection of Poverty, Race, and Healthcare Disparities in Maternal Mortality Crisis

The contextual ground truth is the scandalous maternal health crisis. Among developed countries, the U.S. has the highest infant and maternal mortality rates – triple the others. And it’s only been getting worse. Between 1999 and 2019, the number of U.S. women who died within a year of pregnancy doubled. 

Poverty and race play a key role. Women in counties with middle and high poverty face a 60-100% greater risk of death. Black women are three times more likely to die from a pregnancy-related cause than white women. Indigenous women are also at greater risk.

Lack of access to quality health care can also be deadly. Half of all U.S. counties don’t even have an OBGYN. And fully a third to half of deaths occur in the first three months postpartum – after delivery – when hospitals seldom follow up beyond perhaps one in-office visit at six weeks postpartum.

Studies show that having access to quality health care would prevent 40% of all maternity deaths, regardless of race or socio-economic background.

“Survival should be the least of what we expect and hope for,” says Leseliey Welch. “The idea that we meet and speak to mamas who are so afraid of having their babies and have even been in conversation with a mama who was saying, ‘I just didn’t want to die,’ is horrific.

“There are elements of hospital care that are unsafe for many of us, not just Black and Brown people. Feeling safe, being heard, feeling valued, having a comprehensive care experience, having greater respect and autonomy, all of those things impact our outcomes.

“We should aspire to safe, quality, loving care for every birthing person. One of the things that we lift up and believe at Birth Center Equity is that birth centers are part and parcel of the answer to the maternal health crisis in our communities.”

Improving Outcomes

There is ample evidence that one key to better birth outcomes for parent, mother and child is the involvement of midwives and doulas from the beginning of pregnancy to several months after birth. Birth centers offer a fundamentally different paradigm anchored in preventative care. Indra Lusero and Leseliey Welch say that the participation of doulas and midwives provides the safest and most positive experience for a person giving birth. 

“Doulas are the non-clinical support providers,” says Lusero. “They’re there for the laboring person to provide emotional, physical support, encouragement, education, and a sense of what’s going to happen. 

“The midwife is a clinical provider. I think of midwifery as the original perinatal care provider, preceding even the profession of medicine. People have always had midwives. Humans need assistance during childbirth partly because of our big heads, but also upright position. That, in particular, makes it such that humans can’t totally handle birth alone, like some mammals.”

“When we think about our care systems, midwives as specialists in normal physiological birth, as trained healthcare professionals, have been devalued,” says Welch. “What we know from a public health perspective is that midwifery-led care results in a better experience and better birth outcomes, and is what we call value-based care or a very efficient use of resources for the value that midwives add.”

According to data from Maternal Mortality Review Committees, including midwives in the healthcare system could prevent more than 80% of maternal and infant deaths. In the U.K., where midwives deliver more than half of babies, the mortality rate for mothers is more than three times lower than in the U.S. 

Along with reducing both maternal and infant mortality, midwifery-led care results in fewer preterm births, fewer low-weight babies, and greater rates of breastfeeding. 

A Long History of Exclusion

Given that the benefits of midwifery are well documented, why aren’t midwives playing a central role in the birth process in the U.S.? Leseliey Welch and Indra Lusero observe that, starting a century ago, the medical profession launched a deliberate national campaign to eliminate midwives entirely. 

“Midwives were framed as a problem,” says Lusero. “But the problem that midwives posed to doctors of that era, in particular, was the fact that women and women of color and women of low socioeconomic status, and immigrant women, could serve people in the perinatal period and do it well. That challenged the prestige of white male doctors who wanted to also work in that realm.”

“You’ll also find campaigns that were highly racialized, that undermined Black midwifery in particular, describing Black midwives as unclean and uneducated, and ignorant,” says Welch. “It was political, cultural, multi-layered.”

“It coincided with this historical moment too,” says Lusero. “It was at the beginning of the Jim Crow era. It was the beginning of the Reorganization Act in terms of federal Indian law and policy. Eugenics had informed a lot of the preeminent scholars and thinkers of the day too, so there was this idea that society could be improved through reproduction. Managing the reproduction of society was the key to advancing society.”

“When you have this deliberate undermining and shift, then you simultaneously have a cultural shift to the medicalization of childbirth,” says Welch. “Because in order to keep birthing people coming into hospitals to have their babies, we had to be convinced it was the safest place to have our babies. And from an evidence-based perspective, that is actually untrue.” 

Yet to this day, the campaign against midwives continues. Apart from structural and policy barriers, midwives can face harassment, such as challenges to their licenses and actual criminal investigations and charges.

Profits, C-Sections, and the Rise of Birth Centers in Modern Maternity Care

The profit-driven advent of the medical-industrial complex in the U.S. in the 1920s ushered in the medicalization of birth. Following its relentless campaign to eliminate midwives and home births, the number of in-hospital births rose from 40% in 1940 to 99% in 1955. Today it’s 98%.

With the average cost of U.S. maternity care at nearly $19,000, Uncle Sam spends far more on maternity care than countries with much better outcomes. By contrast, the cost in a birth center is generally half or less. As Leseliey Welch sums it up, “We pay the most and get the worst.” 

As a case in point, 32% of in-hospital births are C-sections, which are both expensive and profitable. While C-sections put mothers at risk for a host of complications, studies show the involvement of midwives reduces C-sections to about 6%.

Nevertheless, the act of giving birth is intrinsically perilous. Midwives are professionally trained and certified providers equipped to identify problems before they become emergencies. When necessary, midwives help coordinate and manage next-level care, and hospitals are critically necessary for precisely such instances, and for those who simply feel safer there. 

Meanwhile, birth centers are growing in popularity and have even attracted venture capitalists.

“Part of how Elephant Circle got involved in creating this network of birth centers is because a venture capitalist had started a birth center and then closed it because it didn’t have the profit margins that they wanted,” says Lusero. “Because it was such a treasured community resource, and Elephant Circle already mainly does policy work in this area, we wanted to see if we could save this community resource.

“Now that’s what we’re doing, and I think it does challenge and shift the economics. We’ve been curious, when folks like these venture capitalists say that it doesn’t have the profit margins they want, what are they really talking about? Because we know that it brings value, and we know that it’s a model that can pay for itself.” 

The vision of birth centers that Leseliey Welch and Indra Lusero have been midwifing is emergent. According to the National Institutes of Health, home births increased by 77% from 2004–2017, while the number of birth center births more than doubled. The trend accelerated in 2020 when the COVID-19 pandemic made hospitals intensely dangerous places to be. 

The approximately 400 U.S. community birth centers today were largely started and are owned by midwives. Because their work is devalued at large, there are structural barriers around payment systems, such as reduced Medicaid and insurance reimbursements, that make it hard to stay afloat.

The great majority of birth centers are owned by white midwives, which is where the Birth Center Equity network comes in. By 2023, it was working with 38 Black, Indigenous and people of color leaders who have opened 14 birth centers and are working actively to open 24 more. It costs about $4 million per startup.

If just 1% of the population shifted to birth centers or home births, it would save $187 million. A 10% shift would save billions. Birth Center Equity says those resources could be reallocated to opening and supporting more birth centers, while helping provide a sustainable business model, along with improved public health and social value. 

Welch says another challenge is optimizing the so-called “fourth trimester” or postpartum period, which is the first three months after delivery. That’s a critical time that’s generally excluded or underserved by hospitals and when a third to half of maternal deaths occur.

“It’s like the baby comes out, and everybody goes away in terms of the care that our systems provide,” says Welch. “In that period of time, we need support and caring and help and advice and love and somebody to cook food and somebody to wash dishes and wash clothes and hold the baby while you take a shower. One of the things that taking birth out of communities has done is also take the community out of birth in a lot of ways. Birth, historically, in many of our cultures, was a family experience and a community experience.” 

“Everybody knew what their role was when that happened in the community, and everybody had a role,” says Lusero. “At Elephant Circle, we’re developing a network of birth centers in Colorado, and we envision offering things in these centers like mental health services that are integrated, that people could come and get even if they didn’t give birth there. These centers can really improve public health. “

“At Birth Detroit, we’re building our birth center with the plan of creating space for other buildings on the property to house values-aligned providers,” says Welch. “When you’re coming to these spaces, you don’t have to wonder if you’re going to get a provider that is going to respect your gender or your attraction orientation or your race or religion because you’re coming to a space that is dedicated to providing care. In our case, our values are safety, love, trust and justice.”

“We know what better looks like and feels like,” says Lusero. “That’s another thing that heartens me: People know it in their bones. People know it in their bodies. People want better. They feel it in their cells.” 

“My hope is that the tides will turn, and we will see a shift to a day when birth becomes a true moral, ethical, economic, and political priority, where we really invest in what the beginning looks like,” says Welch.