Black reproductive justice: Black birthing spaces and support could be the key to maternal health
This article is part of Dreaming Out Loud, a media series written as part of the Bioneers Young Leaders Fellowship Program. To learn more, visit bioneers.org/dreaming-out-loud.
Shaquyla Baker didn’t expect to have a cesarean birth. At the age of 19, she hadn’t planned to become pregnant at all. She was nervous, but she was also excited to become a mother.
During her second trimester, Baker began experiencing daily excruciating headaches, but she dismissed them at first. Between her cravings for salty pickles, a contentious relationship with her boyfriend and the general anxiety of pregnancy, she assumed a poor diet and stress were to blame for her headaches.
“I was definitely feeling in my prime, and really wasn’t too focused on medical issues,” Baker said. “I was just having a baby at [a young] age.”
Soon after the headaches began, Baker began having fits of dizziness and imbalance, unable to move. Her mother pleaded with her to see a doctor, and after several clinical tests, Baker discovered she had preeclampsia — a dangerous pregnancy complication characterized by high blood pressure that can result in death.
Baker’s OBGYN, who was also a Black woman, was responsive to her condition and able to coach Baker through her pregnancy to lessen her symptoms and ensure a healthy pregnancy for her and her baby.
“It’s very beneficial when you have a doctor that knows a lot about your race; she knows the circumstances and things that can go on just within the culture of your body, things that could happen,” Baker said. “When you have someone who knows your culture and knows things that we as Black women go through, it makes me feel a little better.”
While Baker had originally wanted to deliver her baby girl naturally, the risk of complications from her preeclampsia caused her and her doctor to settle on a cesarean-section. Baker’s daughter, Dakota, was a healthy baby girl, and still today, Baker thanks God for her Black doctor and the wellbeing of her and her daughter.
As a Black woman whose serious health condition was not overlooked by her healthcare provider, Baker’s story is somewhat unusual. According to recent statistics regarding maternal health, it could be the reason why she and Dakota are alive today.
Black birthing parents are dying at an alarming rate
In the United States, Black women and birthing people are consistently at the mercy of a system of care dominated by white, male medical practitioners and wrought with sinister and life-threatening failures. The result is a public health crisis plaguing the lives of Black birthing people, who suffer staggeringly worse maternal health outcomes.
Hospitals in the U.S. that serve Black communities — where 75% of U.S. Black women give birth — have been found to provide lower-quality maternal care and have higher rates of maternal complications in their patients. Moreover, when surveyed, both Black and Hispanic women reported receiving poor treatment from hospital staff because of race, ethnicity, cultural background or language.
The U.S. spends more on healthcare than any other developed nation, yet it ranks second to last in healthcare coverage and records the highest maternal mortality rate. According to the Centers for Disease Control and Prevention (CDC), more than 800 new and expectant mothers died in the U.S. in 2020, with 1 in 3 pregnancy-related deaths occurring due to life-threatening postpartum complications 1 week to 1 year after giving birth. More than 80% of those deaths were preventable, and a disproportionate number of the birthing parents suffering were Black.
Non-Hispanic Black women in the U.S. are 2 to 3 times more likely to die from pregnancy-related causes than non-Hispanic white women. For Black women over the age of 30, this figure increases to 4 to 5 times more likely than white women.
Most research that seeks to explain this disparity in maternal health outcomes focuses on a Black birthing person’s exposure to risk factors during pregnancy, including poverty and low socioeconomic status. However, the same disparity holds true across education levels and socioeconomic statuses. One could easily suggest that in the United States, nothing — not wealth, education or status — is enough to prevent Black birthing people from dying during and after pregnancy.
“It is literally being a Black person — a Black woman — in this world that has fatal outcomes,” Walton said.
Chronic stress is worsening Black birth outcomes
To fully understand these maternal health disparities, we must be willing to acknowledge the deeply entrenched anti-Black racism in our society that continues to violently devalue and dehumanize the health of Black folks as well as the exposure to stress that comes with being systemically marginalized in this country.
Given the United States’ climate of racial inequity, Black birthing people are far more likely to be chronically exposed to stress. As a result, they produce about 15% more of the stress hormone cortisol than white women, according to the National Heart, Lung and Blood Institute. High cortisol levels raise the risk of pregnancy complications — including conditions such as hypertension and preeclampsia — that can result in preterm births and low birth weights in infants. Preeclampsia is 60% more common in Black birthing people than white birthing people.
These conditions are far more common in U.S.-born Black women than their African-born counterparts.
Black women in the U.S. have yet to experience a reality in which their quality of care fosters better birth outcomes.
“There’s never been a moment in which Black women are having equal birth outcomes to our white counterparts because we’ve always been put under excessive stress, we’ve always had lower access to nutrition, and lower access to prenatal care or whatever the case may be,” said Niria White, Interim Birth and Postpartum Director for Mama Sana Vibrant Woman – a non-profit organization providing culturally resonant and quality prenatal and postnatal care to people of color in Travis County, Texas. “There’s never been a moment where we’ve had everything we need for a majority of us to have positive birth experiences.”
While the solution to ending these maternal health disparities for Black birthing people is a dismantling of the racist medical institution, Black birthing people like Shaquyla Baker are turning to Black birthing spaces — maternal care settings and experiences that provide a refuge from the daily violences of anti-Black racism in the healthcare system — and ancestral birthing practices to make their pregnancy and birthing experiences safer and healthier.
When Baker became pregnant with her second child, Marlon Jr., she worried about the potential of a pregnancy with similar or worse complications than those she experienced when she was 19. She was more mature now, more health conscious and in a loving relationship, but with family unable to attend her son’s birth, her pregnancy had become a lonely experience.
“I definitely wanted somebody to be there that’s in our corner, to emotionally support us during the experience,” Baker said. “That’s really why I wanted to go the doula route. I didn’t have my mom, but I did want somebody who could kind of take her place during that experience in the hospital.”
Black maternal health necessitates Black spaces
Doulas — often referred to as “birth workers” or “companions” due to the term’s association with slavery — have always been a part of many communities of color, taking up a role that allows them to support and advocate for a birthing parent at their most vulnerable. Birth workers are non-clinical health professionals who provide emotional, physical, and educational support for birthing people and families during and after pregnancy and birth.
“[Having a doula] made a complete difference,” Baker said. “It made situations a lot smoother just talking to somebody outside of family, outside of friends, somebody who actually just wants to help you, not because they have to, they just want to help you. It was definitely an experience I think I needed.”
It is undeniable that Black birthing people need their own spaces to be afforded maternal experiences that are self-determining, healthy and that holistically tend to the wellness of the birthing parent and their family. Birth workers offer this much-needed space, providing a buffer between Black folks and the anti-Black racism that has infested the traditionally white-centered healthcare system.
“I definitely felt 10 feet tall going to every appointment knowing I was important, knowing this is my baby,” Baker said. “It felt great.”
When they are involved in a birthing experience, doulas are associated with improved maternal health outcomes for Black birthing parents and their babies.
A 2021 study of Medicaid beneficiaries receiving birth-work support revealed lower rates of cesarean and preterm births when compared with other pregnant individuals enrolled in the program. Furthermore, birthing persons in communities that are most vulnerable to adverse maternal health outcomes were two times less likely to experience a birth complication, four times less likely to have a low-birth-weight baby, were more likely to breastfeed and were more likely to be satisfied with their care.
Birth work and birthing companionship has also been linked to reduced rates of postpartum depression and anxiety, and increased positive feelings about birthing experiences and the ability to influence one’s own pregnancy outcomes.
Before her pregnancies, Baker had always assumed doula care was for the bourgeois. Doula care and support is often seen as a luxury reserved for wealthier white women, stemming from the hefty price tag that accompanies many doula services on top of the already overwhelming expense of pregnancy and childbirth.
However, organizations such as Mama Sana Vibrant Woman (MSVW) and Giving Austin Labor Support (GALS) are leading in providing access to culturally responsive prenatal, birth and postpartum care for communities that have been systemically barred from their ancestral birthing spaces. These organizations provide Black and brown birthing parents and their families with access to pregnancy and birthing care, community resources and healing practices at no cost. They offer spaces to receive culturally responsive care and to build community through educational classes, support circles and in-home childcare aid. GALS has even worked in partnership with the local county sheriff’s office to offer doula support and educational programming to pregnant and postpartum incarcerated individuals.
These types of community-based doula programs build on the strong relationship doulas establish with mothers throughout pregnancy, birth and the postpartum period to promote ongoing care and support.
It was through the GALS doula program that Baker was able to find the support she was longing for, with her new doula, Angel Walton.
“Angel, she was so touching. She was so concerned about my feelings,” Baker said. “Just the experience of Angel being my doula — I can’t just say she was my doula, she was my family’s doula.”
Birth work and the ancestral embodiment of holding Black space
Tall cypress trees line the riverbank. Their green, yellow and red leaves sway in the breeze, reflected in the clear water below. It’s not unusual to see steam rise from the surface of the San Marcos River on a brisk morning, or to catch swimmers weaving their way through Texas Wild Rice that is rooted in the riverbed.
The San Marcos River in San Marcos, Texas holds sacred water; the springs that feed the river are a spiritual site for Indigenous Peoples and a guide for sacred pilgrimages. For Angel Walton, the river provides a conduit for connection with her ancestors and her gods, who she calls to and often prays to, before each birth she attends.
When called on to assist in the birth of a client, Walton lights a candle on her ancestral altar welcoming the new soul, and she heads to the river.
“I’m usually called to the water,” Walton said. “Babies are living in water, and they’re transitioning. I think all water is connected. I end up being at the river just calming my spirit and washing away what needs to be washed away so that I can be clear, clean and present for that person and that baby and that family, in particular, for the ceremony of birth.”
Just as she is drawn to the river, Walton feels called by her ancestors to be a doula and create Black birthing spaces in which Black birthing people are able to dream up a pregnancy and birthing experience that tends to the mind, body and spirit — an experience that is difficult to achieve in an otherwise anti-Black, racist society.
Walton describes her work as a birthing companion as energy work and work that embodies her ancestral practices of connection and creating genuine relationships that are nurturing and based in community. To Walton, creating and holding Black birthing spaces is a focal point in her work as a doula and is critical in saving the lives of Black women and birthing people.
These spaces are particularly profound for births that happen inside of a hospital, Walton said.
“Human beings, mammals, go into places where it’s dark, they go into a place where they feel safe [during birth],” Walton said. “They go into a place that feels so quiet and relaxing, and hospitals are pretty much the opposite of that, especially for Black and brown bodies.”
An ancestral history of community-based support
Doula practices existed for centuries prior to the earliest recorded practices in the U.S., with a history and legacy deeply rooted in African ancestry.
When a birthing parent in West Africa gives birth, they are surrounded by community and embraced by the love of female relatives, who build altars to protect the spirit of new life and create drumming circles to commemorate the new arrival. The sacred ceremony of birth is attended by a midwife — a health professional who cares for mothers and their newborns during childbirth — and a doula, who supports the birthing parent through their experience of labor and childbirth.
“Birth was a community event as much as it was private and sacred and secret,” Niria White, the Interim Birth and Postpartum Director for Mama Sana Vibrant Woman, said. “It was a secret thing that happened, but for women, particularly women who had given birth, this was a moment to come together and care for each other.”
African midwives and doulas were more than just baby catchers, traditionally performing roles as spiritual healers, nutritionists, breastfeeding consultants, postpartum doulas, family planning counselors and advocates who provided resources, care and Black birthing spaces for their birthing communities.
“When you move away from the medical way of understanding birth and lean more into the natural, the holistic, the physiological — the body’s response to birth — that’s what our ancestors did. They focused on that,” White said. “How was your mind, your body and your spirit moving throughout this portal of birth?”
Experienced midwives and doulas were among the many enslaved persons who survived the middle passage of the Trans-Atlantic slave trade. They were exploited as medical practitioners who could ensure the health of reproducing enslaved women and their newborn babies to expand their labor force, and to care for the pregnant and birthing wives of African slave owners. It’s from these African traditions, born out of African ritual, that the roots of African American midwifery and doulaship in the U.S. grew.
Black midwives and their accompanying doulas were crucial figures in their communities, particularly among enslaved persons. By the mid-to-late 1600s in the U.S., while these birth workers were still subjected to the brutality of slavery, Black midwives, doulas and their birthing traditions became the primary sources of prenatal, birth and postpartum care for all birthing people in the country and were instrumental in the preservation of Black maternal and infant health.
According to a 2003 study published by the American College of Nurse-Midwives, between the 1600s and early 1900s, nearly half of all babies born in the U.S. were born into the hands of midwives and the birthing companions that studied under them.
Even after Emancipation, Black midwives, affectionately known as “granny midwives,” continued their vital, sacred and ancestral work with both Black and white birthing people in the U.S. South, particularly in rural communities, where access to maternal care and resources for birthing people were minimal. Granny midwives traveled throughout the South, ensuring that Black birthing spaces were available to Black families regardless of their geographic location or ability to pay, mitigating the disparities experienced by Black birthing parents in the health care system.
Despite the racist institutions of slavery, Reconstruction and Jim Crow, granny midwives and doulas held onto and passed down African birthing traditions that included rituals and herbal remedies and served as connectors to the spiritual and cultural legacies of African birthing practices, birthing Black babies during life in a Diaspora.
Racism has erased Black birth work in the U.S.
The practices of midwifery and doulaship create Black birthing spaces that challenge the racialization and overmedicalization of birth with an emphasis on community-based care, intimate relationship building, prenatal and postpartum wellness and avoiding unnecessary interventions that can, and often do, spiral into dangerous birthing complications.
Yet today in the U.S., only 6% of midwives are Black and 16% of doulas are women of color.
These statistics are largely due to racist beliefs that eroded the cultural practices of doulaship and midwifery in Black communities. By the early 20th century, a reformation campaign was launched by physicians, nurses and public health departments to shift control of birth from community-based and traditionally trained Black women to the power of the white and male-dominated medical profession.
“We’re getting eradicated because of these changes in the healthcare system, and it just happens so fast,” White said. “I think in the span of 20 years, like 30 to 50% of midwives who are primarily birthing in the South were eradicated, are just non-existent.”
Medical and health professionals began spreading false and racist claims that Black midwives and birthing companions were at fault for the high maternal mortality rate due to a lack of education, skill and cleanliness, demoting the traditional practices to barbarism and superstition.
The annihilation of ancestral birthing practices was further accelerated by the signing of the Sheppard-Towner Act of 1921 into law. The Act created regulatory barriers for education and licensure that effectively outlawed out-of-hospital birthing practices and workers without institutionalized training. This law was accompanied by a push from the American Medical Association in 1948 to standardize medicine and eliminate out-of-hospital healers.
According to the Journal of Midwifery and Women’s Health, physicians made up the vast majority of primary care providers by the 1940s, and home births were essentially replaced by hospital births. The move to hospital births accompanied a reliance on intervention methods such as cesarean deliveries, artificially rupturing membranes and epidurals, which may not have been medically necessary in low-risk pregnancies.
“It was never about actually prioritizing women’s health, women’s bodies, maternal health or anything like that,” White said. “White women have always had better birth outcomes than we have, but their birth experiences aren’t necessarily better. They weren’t necessarily having beautiful, magical births in the early 20th century. They were being drugged and put to sleep in weird, violent ways. Weird things are still happening, it’s just that Black women are getting the worst of this already weird world.”
Racism continues to harm Black birthing bodies
The U.S. has a long history of the erasure and theft of ancestral practices that have proven to save Black lives. With anti-Black racism being intimately intertwined in the foundation of gynecology, the profession itself was built on non-consensual medical experimentation and the exploitation of enslaved Black women.
In the 1840s, James Marion Sims, a white gynecologist in Montgomery, Alabama, performed excruciatingly painful experiments without anesthesia on enslaved Black women, often while other doctors observed. While he eventually achieved the title of “Father of Gynecology,” he did so only through this life-threatening experimentation.
Many of Sims’ experiments were unsuccessful, but he continued to perform procedures on enslaved Black women from 1845 to 1849, needing only the permission of the enslaved women’s “owners.” Often drugged and unable to refuse treatment, Sims’ patients were powerless to protect themselves from the racist medical exploitation that he performed.
It’s evident that current medicine was built on the backs of Black women and birthing people — a practice that has altered how doctors and medical professionals have treated Black patients throughout the course of U.S. history.
The 19th century saw the emergence of eugenics: the inherently racist and ableist ideology that labeled certain people, particularly Black people, unfit to have children due to possessing “undesirable” traits. The idea behind eugenics was that the human race could be bettered through selectively breeding people with specific traits thought to be genetic, like intelligence, work ethic and cleanliness.
This belief became widely popular with upper-class white Americans who sought to control the populations of people deemed inferior and with undesirable traits — immigrants, people of color, poor people, unmarried mothers, the disabled, the mentally ill. Numerous powerful actors chose to adopt eugenics, including Theodore Roosevelt, Andrew Carnegie and, most notably, Margaret Sanger — the founder of Planned Parenthood.
Sanger is renowned for founding the American birth control movement. She spoke at numerous eugenics conferences, including the women’s auxiliary of the Ku Klux Klan, to generate support for the use of birth control. When she spoke, she often referred to birth control being used to facilitate a process of weeding out those unfit to bear children and to prevent birth defects.
Though it is claimed that Sanger eventually distanced herself from eugenics, she endorsed the Supreme Court’s 1927 decision in Buck v. Bell, which allowed states to sterilize people considered mentally “unfit” without their consent and sometimes without their knowledge — a ruling that would take eugenics to its horrifying extreme with the forced sterilization of tens of thousands of people of color in the 20th century.
California had the nation’s largest forced sterilization program, sterilizing about 20,000 people beginning in 1909. More recently, California prisons were exposed for falsely diagnosing incarcerated women with cervical cancer and coercing the women to remove their reproductive organs — with doctors sometimes performing non-consensual hysterectomies after they gave birth. The Center for Investigative Reporting also found that the state paid doctors nearly $150,000 to perform tubal ligations on almost 150 women, a procedure the women say was done under coercion.
Between 1997 and 2014, nearly 1,500 women were forcibly sterilized in California prisons, most of them Black.
“What we’re seeing now is a reflection of how we’ve always been treated, and I think we’re just now able to see the data,” White said.
Black futures require Black birthing spaces
Black women’s bodily autonomy and health have been consistently attacked throughout the course of U.S. history. This violence has only been exacerbated by the recent U.S. Supreme Court decision to overturn Roe v. Wade, which further complicates pregnancy and childbirth by denying millions of birthing bodies their constitutional right to abortion and abortion care.
According to a 2021 study conducted by University of Colorado sociologist Amanda Stevenson, banning abortion nationwide will lead to a 21% increase in pregnancy-related deaths for all birthing people and a 33% increase for Black birthing people specifically.
At the state level, research has concluded that the most restrictive abortion laws tend to be associated with the poorest maternal health outcomes. A recent study published in the journal of American Public Health Association revealed that states with higher abortion restrictions had a 7% increase in total maternal mortality rates.
“They want people to be having children so that we have a working class,” White said. “Eradicating abortion is a way to reduce the amount of agency for women, and to have more babies.”
It is imperative that Black birthing people have access to birthing spaces in which they are valued and humanized while they endure one of the most vulnerable — and sacred — experiences of their lives. Community-based care, like birthing work, is key. However, according to White, more birth workers alone won’t bring the U.S. out of the depths of the Black maternal mortality crisis.
And, birth workers can’t be expected to singlehandedly mitigate the anti-Black racism deeply embedded within the medical landscape. The healthcare system is responsible for the deaths of hundreds of Black mothers every year, and the creators and enforcers behind that same deadly system should be held accountable for their role in the current state of maternal health outcomes.
Today, the American College of Obstetricians and Gynecologists agrees that reproductive justice — agency over one’s body and access to quality care — and equitable maternal health outcomes cannot be achieved without addressing racial bias in the medical field.
“We should start there, bringing it back to listening to the individual, listening to our bodies, and we should stop trying to navigate the medical world as a Band-aid and really focus on real healing. Then we would actually be able to find some reproductive justice,” White said. “That would be so nice.”
Real, lasting change will require us to examine every part of our societal processes that are steeped in anti-Black racism — that are permeated with racial violence — and to deconstruct our sexist and dehumanizing understandings of Black women’s bodies. In doing so, we can ensure there is a focus on providing Black birthing people with greater access to healthy foods, quality mental health care, a balance of home and work environments, spaces to care for ourselves and others and quality maternal care that is conducive to safe and healthy pregnancies.
“I have faith that we can get back to a place where at least we’ll be able to create pockets of safety for women to be able to have this beautiful experience, at least a little bit stress-free, just for that moment of time,” White said.