Maternity Care in a “Majority Minority” Country

Race-based maternal health disparities are no longer a concern of the minority — they are a concern of the majority. And they should be a top priority. If Medicaid doesn’t make room for alternative, potentially life saving maternal health models, we risk endangering the health of generations to come.

Two weeks ago the news from the Census Bureau that non-white children make up the majority of those under the age of one year created a firestorm of media headlines across the nation. These demographic shifts have many implications for our nation, but my first thought was this: The majority of the babies being born in the US are now at serious risk for a whole host of maternal, fetal, and infant health problems.

Why? Because women of color have significantly higher rates of pre-term birth, low-infant birth weight, maternal, and fetal mortality.

Race-based maternal health disparities are no longer a concern of the minority — they are a concern of the majority. And they should be a top priority. According to Amnesty International’s 2010 report, African American women are four times more likely to die during childbirth than white women, a rate that has not improved in over 20 years. Data from 2008 showed that African American women also had an infant mortality rate that was twice that of white women. While only comprising 16 percent of births, African-American women experienced 30.4 percent of the infant deaths.

Similar statistics and disparities exist for Native American women, Asian Pacific Islanders and Latinas to varying degrees — but with few exceptions, the rates for all these groups are higher than for white women. The United States lags behind 49 other countries in our maternal mortality rates, and 40 other countries in our infant mortality rates, a fact that was reiterated in an article in Sunday’s New York Times Magazine. The piece was a profile of Ina May Gaskin, famous for her work promoting out of hospital birth as a midwife in rural Tennessee. What the article neglected to talk about, however, was maternal health disparities for women of color.

The cause of race-based maternal health disparities is likely complex and intimately connected to issues of poverty, racism, and quality of health care. For many advocates like Gaskin, the midwifery model of maternity care is an often-touted way to address these disparities. I myself, as a doula and frequent writer about the connections between race and maternal health, have explored how the midwifery model, which emphasizes patient-centered care and utilizes fewer interventions, could successfully reduce these disparities. 

In order to truly address these long-term and seriously detrimental race-based maternal health disparities, we need to make room for innovation. Our current model is broken. It’s failing us. That model is one that is dominated by hospital birth (98 percent of all births in the United States happen in hospitals) and are attended by obstetricians likely using interventions. The place where that innovation is most desperately needed is Medicaid-funded maternity care. According to Amnesty International, “Medicaid pays for over 40 percent of births in the United States, and costs related to pregnancy and birth account for over one quarter of all hospital charges billed to Medicaid.”

There is evidence to back the claim that midwifery care could be the innovation we need to improve maternity care, especially for women of color. Jennie Joseph, a midwife in Orlando Florida who runs a birth center and maternal health clinic, says she’s almost eliminated the maternal health disparities typically seen in her low-income Black and Latina patients. Recent findings by the American College of Nurse-Midwives also showed improved outcomes with midwifery care.

But the problem is that midwifery in the United States just isn’t reaching women of color. Recent data from the CDC showed a 29 percent increase in the number of women having home births — but the vast majority of that increase was due to white women choosing home birth. Many have also pointed out that midwifery care won’t be accessible to women of color until midwives themselves are more representative of the communities they are trying to reach. It remains an overwhelmingly white profession, and for those midwives of color who have ventured into the field, challenges abound. Around the same time the census data was released, a group of midwives of color resigned from the leadership of the Midwives Alliance of North America, one of the main professional associations for midwives in the United States. Their resignation, explained in their letter to the MANA leadership, named instances of institutional racism and ongoing frustrations within the organization.

Claudia Booker, an African American midwife in Washington DC who was among those who resigned, talked with me about a bigger challenge — one that will affect any maternal health providers who want to work with low-income populations and communities of color: the business model. She explained that Medicaid and its reimbursement fees make it almost impossible for the midwives of color she knew to stay in business while serving primarily low-income women of color. Out-of-hospital midwives receive just $1200 for each Medicaid birth, which includes all pre-natal visits and the labor itself. That’s in contrast to the $4,000 that midwives charge individuals for similar services.

Other medical providers are able to cater to Medicaid patients, but the thing that keeps them in business is volume. If they can handle many patients in a day, than the lower reimbursement rates can be counteracted. The problem, Booker explained, is that having a high volume practice goes against the midwifery model.

“If we were able to give quality care to clients at 45 minutes each, and be able to handle enough clients to live well, then Medicaid would be the answer for us. But we can’t do that. You just can’t say your five minutes are up and you’re gone.”

It’s this patient-centered and time-intensive care that may be the key to eliminating disparities, but the Medicaid system leaves little room for this kind of practice. That means that a maternal health model of care that could eliminate disparities might never reach the population that most needs it.

I’m not the only one who believes we need innovation in maternal health. The Center for Medicaid and Medicare Innovation just announced 43 million in funding for new approaches to prenatal care that address the problem of premature births — something that leads to much higher mortality rates, and a host of other complications for newborns. But once again it looks like midwifery will be kept out of this discovery process — the only eligible providers are those who see at least 500 births per year — something that few midwifery practices or birth centers do. These requirements are based on the desire for statistically significant findings, but they might just exclude those who can actually produce the results they are seeking.

It’s hard to imagine that a medical provider who is forced to carry a high volume of clients will be able to provide the care necessary to eliminate race-based health disparities. If Medicaid doesn’t make room for alternative, potentially life-saving maternal health models, we risk endangering the health of generations to come. The challenges are clear, what we require are the innovative solutions. Our nation’s health depends upon it.