In December, Rosalina Lozada, five of her fellow nurse-midwives, and one nurse practitioner, who all provide midwifery care at NewYork-Presbyterian Allen Hospital in Inwood, Manhattan, all received the same email within minutes of each other:

This letter is to inform you that the Hospital will be eliminating your position, as a Nurse Midwife, at the Allen Hospital.

The hospital later said the date of elimination would be March 3.

Lozada has been a midwife for 25 years and has worked at Allen for more than a decade. She read the letter in disbelief.

“No reason was given,” she said. “Why? It doesn’t say. By whom? It doesn’t say. And it certainly didn’t say how the patients are going to be cared for.”

The midwives were horrified, not only because of how the termination impacts their own livelihoods, including their union pensions and benefits, but also because they know exactly how much the community in Upper Manhattan and the South Bronx needs access to the safe, effective, and culturally appropriate pregnancy care they provide. Obstetricians are also on staff, but midwives are uniquely important to pregnancy outcomes.

Nurses on the labor and delivery floor at Allen confirmed in interviews to Rewire News Group that the midwives are crucial: They are the people who listen to patients’ concerns and help them understand what’s happening, who notice a subtle change in a fetal heart reading, who flag a rise in blood pressure, and who are on-call 24 hours a day for any postpartum concerns, when many serious maternal complications occur.

Allen serves primarily low-income Medicaid patients, a majority of whom are recent immigrants from Latin America and the Caribbean, particularly the Dominican Republic. Due to health impacts of racism and social inequity, underresourced Black and brown communities like the one the hospital serves are already at higher risk for complications during pregnancy and childbirth that can lead to deaths and long-term health problems. According to the Centers for Disease Control and Prevention, more than 80 percent of maternal deaths between 2017 and 2019 were preventable, highlighting the need for improved health care and social services, especially for underserved communities.

In New York City, Black women are more than nine times more likely to die as a result of pregnancy and birth than white women. Mayor Eric Adams recently announced an initiative to respond to this crisis, including expanded access to midwifery care. And yet, Allen’s decision to eliminate midwifery care seems to do the opposite in an already-vulnerable community.

Midwifery is effective

Years of research have shown that more midwives lead to fewer deaths and complications.

“When midwives are integrated into care, we know that patient outcomes improve,” said Mimi Niles, a certified nurse-midwife and assistant professor at the New York University Rory Meyers College of Nursing. “At the clinical level, we know that there are fewer preterm births, there are fewer miscarriages, higher rates of vaginal birth, lower rates of cesarean births, lower rates of low birth weight infants.”

And yet, as several researchers pointed out, while the percentage of births attended by midwives in the United States has slowly crept up from about 3 percent of all births in 1989 to about 10 percent of all births by 2021, midwives often face opposition from hospital systems. This is in stark contrast to other wealthy countries, where midwives are the default provider for uncomplicated pregnancies—and where outcomes are better.

“We know that clinically the case for midwifery is strong,” Niles said. “As a researcher, it’s frustrating to feel like you have to keep reproducing the same research to tell the story.”

Niles is one of the researchers at the University of British Columbia’s Birth Place Lab, which has conducted in-depth research on the effects of midwifery care. In a landmark study, the group found that U.S. states with more midwives per person and more access to midwifery care across birth settings had significantly better outcomes for both pregnant people and babies.

‘The midwives are the backbone’

In the wake of the Allen announcement, NewYork-Presbyterian faced stiff criticism from local elected officials, including all of whom spoke out against the hospital’s decision at a rally in January. At that event, Edgardo Acevedo, deputy public advocate for housing equity, called on the hospital to reinstate the midwives.

”At this hospital, 80 percent of the women seeking care are Black and brown, and it’s not only about offering health-care services, it’s about building community connections and building a true meaning of health for the people who are living here,” Acevedo said, describing the hospital administration’s decision as “reflective of the racial inequity that has overshadowed the beauty of this city.”

At the end of January, New York Attorney General Letitia James wrote a letter to NewYork-Presbyterian expressing alarm at the planned elimination and urging the hospital to reconsider. The hospital initially responded by saying its perinatal care program was evolving, according to Patch, but it quickly seemed to change tack, insisting midwives would still be available at Allen—but apparently just not these midwives, all of whom are unionized employees with many years of experience; the longest-serving among them has been at Allen for 35 years. Similar to the patients they serve, all the midwives speak Spanish, and many are also women of color.

Angela Smith Karafazli, a senior director of media and public relations at NewYork-Presbyterian, said in a statement that the new midwives would be managed by Columbia University, which is a partner of the hospital.

“Our perinatal care teams at NewYork-Presbyterian Allen Hospital—which will include midwives affiliated with our partners at Columbia—are focused on providing the highest standard of care, including the very best patient experience, to mothers and their newborns in our Northern Manhattan community,” according to the statement.

The hospital did not respond to repeated follow-up questions from Rewire News Group about why the current midwives are being let go, when new midwives would be starting, or any other details of the new service. Columbia did not respond to multiple requests for information about their plans. On Columbia’s website, there is a job posting for a midwife position at Allen, but it is not a union job and doesn’t mention a preference for Spanish language skills.

Several employees said morale and trust in hospital administration is low, and concern for job security and patient safety is high. Confidence in the system had already been degraded by the fact that Columbia OB-GYN Robert Hadden sexually assaulted patients for more than two decades, and the university allowed him to keep working despite serious complaints and investigations—a decision that several Allen employees noted did not result in anyone losing their job.

Two labor and delivery nurses at Allen, who spoke to Rewire News Group on condition of anonymity because they fear retaliation from New York-Presbyterian, expressed shock and fear about how patient safety would be impacted by the loss of the midwives and confusion about the plan going forward, which they said has not been communicated to them.

“The midwives are the backbone of the Allen,” one nurse said. “Most of these midwives have been here embedded in our culture for 20-plus years. They speak Spanish and they have a connection with our patients. If the patient has a 40-minute long story, the midwife is patiently listening and takes the time to explain everything. It’s just more personalized care. I think taking that human layer out of our practice—it’s really sad.”

“We are supposed to be in the business of taking care of people,” a second nurse said. “The midwives have given multigenerational care: Some have been there long enough to deliver women that they deliver as babies, so they’re well-known in the community.”

A history of sidelining midwives

“It just kills me, because throughout history, midwifery has been attacked,” Lozada said. She means that in the broader U.S. context, but she also means it locally, and specifically at Allen.

The midwifery program at Allen is the one of the oldest such hospital-based service in the country, with roots going back to 1955. But it has been beset by difficulties.

In 1999, a whistleblower told federal prosecutors that the hospital was engaged in Medicaid fraud, billing for births as if they had been attended by physicians, when they had really been attended by one of the more than 20 midwives who practiced there. (Physician-attended deliveries are paid out at a higher rate by Medicaid and tend to be more lucrative overall than midwife deliveries.) As a result, a lawsuit was brought against Columbia, which the university eventually settled in 2002 for $5.1 million.

Immediately after that scandal, in 2003, the hospital administration suddenly announced that midwives’ scope of practice would be limited: The midwives say the hospital no longer allowed them to attend births, but limited them to triage (admitting and care planning) and postpartum care. This is despite the fact that, according to New York state law, midwives are licensed reproductive and sexual health providers who may attend labors and births. But the administration argued that the pregnant people of the community had too many risk factors—were essentially too unhealthy—for midwifery, though there was no evidence the demographic had changed. What followed was the decimation of the program; over 80 percent of the midwives left, unwilling to have such limits put on their practice.

Although only seven midwives eventually remained and their practice curtailed, they continued to play a vital role. Notably, the midwives and nurses said, because there are usually only two obstetricians on duty at any given time, the midwives have actually continued to attend to labors and births, which they are allowed to do only when an obstetrician isn’t available. Two obstetricians can’t be everywhere at once—there are generally multiple C-sections each day, and the hospital saw more than 1,800 births in 2020.

The midwives also staff a 24-hour hotline that patients can call with questions once they are home with their babies.

“They call at 3 a.m., and we answer—always. Who will take these calls?” Ingrid Deler-Garcia, a midwife at Allen, said. “When someone says they have a fever, or their blood pressure is rising, we tell them to come in right away. And then: Whew. We kept her healthy.”

Impacting quality of care

The hospital saying it will hire new midwives was not comforting to anyone who agreed to an interview for this story. One veteran Allen midwife who requested anonymity because she is taking a bedside nursing role at a different NewYork-Presbyterian hospital to maintain her union benefits, said it was all about power.

“It’s a matter of control,” she said, explaining that the midwives being hired through Columbia would not be members of the union.

Lozada agreed.

“What they care about is the bottom dollar because they believe that having midwives hired by Columbia University is going to save them money in the long run,” she said.

There is also the fact that cultural knowledge impacts quality of care. Tanya Khemet Taiwo, a midwife, researcher, and professor of midwifery at Bastyr University, said both midwifery care and culturally concordant care—care that honors cultural context—are beneficial to outcomes.

“A lot of culturally concordant care is knowing what questions to ask,” Taiwo said, explaining that if you don’t know a patient’s cultural norms, you could miss or dismiss something important.

Lozada, who is Dominican, said she and the other longstanding midwives understand their patients’ lives.

“We know the old wives tales that prevail in our culture, like the idea that a mom is not supposed to take any medication: If they have a simple cold, they’re not supposed to take Tylenol,” Lozada said. “So we tell them: ‘No, you can take Tylenol. You don’t have to suffer. It’s not going to harm the baby.’”

“I know how the women raise their children,” she added. “I know what home remedies they take or their moms make for them when they’re sick. I eat the same foods they do.”

Helena Grant, the president of the state affiliate of the American College of Nurse-Midwives, said she is concerned about several New York City institutions that are attempting to sideline midwives. She said one explanation is capitalism in health care: Some of these attacks seem to be around union benefits and revenue.

But that’s not the whole story, she added. There’s also an element of dehumanization and devaluing of patients’ lives.

“The hospital does not seem to believe that the women and birthing people of that community deserve continuity of care,” Grant said. “It is disgusting and despicable, that Black and brown women don’t deserve to know the people who touch their vaginas, their cervixes—that it can just be randomized.”

“What it really speaks to is, in our society, who is seen as deserving and who’s not deserving,” Grant added. “Who deserves to be in comfort and familiarity with their health-care provider … You’re giving birth to another human. What is more comforting than to be around people you are familiar with when you are in pain? When you’re afraid? But that community has had that taken from them.”

Jennie Joseph, a midwife, educator, nonprofit founder, and national advocate for midwifery, agreed that racism is often the root cause of midwifery being sidelined. She said you can see the effects of the loss of midwifery—and respectful care more generally—in the elevated maternal mortality data for Black women.

“If you remove respect, if you remove dignity, if you remove actual compassion, if you remove listening, then all of these things show up as poor outcomes,” Joseph said. “It’s not physiological. So it’s also preventable. We’ve made a political and unfortunately a societal agreement that we don’t care.”

Asked what she thinks the impact of these firings will be, Joseph was blunt.

“The fact that these midwives have longevity in that community immediately tells me that this is going to be devastating and lives will be lost,” Joseph said. “And I know that sounds dramatic, but yes, life will be lost.”