During Black Maternal Health Week, Rewire.News is joining the national conversation on Black maternal health and sharing stories from the frontlines of the reproductive justice movement.
An abortion clinic might seem like an unlikely space to provide midwifery services, but CHOICES Memphis Center for Reproductive Health is setting a new standard for covering the full spectrum of reproductive health-care needs.
Rewire.News sat down with Nikia Grayson, a public health anthropologist, reproductive justice advocate, and certified nurse-midwife at CHOICES, to talk about her journey to the all-inclusive clinic; the role of Black midwives in the South; what it means to provide evidence-based, holistic care; and how the clinic is managing during this time of pandemic and uncertainty. The following interview has been edited for length and clarity.
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Nikia Grayson: I didn’t start off as a nurse-midwife; my undergrad degree is actually in journalism. I went to Howard University and wrote for, and was the photo editor of, the Hilltop. I loved it.
I ended up going on this trip to West Africa with my best friend and saw sickness in a different way. And when I came back, I started working at a transitional housing HIV program and was really struck by how the HIV virus was devastating the Black community. So I decided to get my master’s in public health, with a focus on HIV. Then my husband accepted a job in Memphis, working in radio.
I almost felt like we had stepped back in time. It was not a progressive city, even though Memphis is considered a major city by many here. But it was hard for me initially. I like to keep to myself, but knew I had to find a community. While I was in a master’s in medical anthropology program, I worked on a project with the March of Dimes. At the time, Memphis had the highest infant mortality rate in the country, and African American babies were dying at greater rates.
I interviewed families, did focus groups, and it really struck me that their loss was generational. I started to dig deeper to figure out some things we could do at the community level and stumbled on information about Black midwives in the South. Then I realized there were no Black midwives here [in Memphis], but they were historically seen as a vital part of the community. They weren’t people who just caught babies or provided care for pregnant people; they were healers who provided tinctures, herbs, and all sorts of things.
Black midwives—called “granny midwives” and later “grammidwives”—were run out of business by a white patriarchal system that didn’t value them or their contributions. These were traditions and skills brought with us and passed down from generation to generation.
At that point, I felt that I was being called to be a midwife. I told my husband and he was like, “You don’t even like people, what are you talking about?” I do! I just don’t want to be with people all day. I really feel like I was called to do this.
So I went to nursing school and then did a doctorate in nursing, with a post-master’s certificate in family nursing and nurse midwifery. While I was doing that, I worked at Planned Parenthood, doing sexual and reproductive health education. CHOICES is about a mile from the local Planned Parenthood. The executive director, Rebecca Terrell, reached out to me; we got together at a midwifery conference. Over dinner, she said [she] wanted to add midwifery services to the clinic. I said [in disbelief], “You’re a first-trimester abortion clinic in the South and you want to add midwifery services?” And she responded: “I really feel like we should have this comprehensive model of care, and that the anti-abortion folks have really commandeered birth.” You see, people who have abortions also have babies, and we should be able to serve them throughout the reproductive spectrum.
How are you holding up as a health-care professional during the COVID-19 pandemic? What are some of the safety precautions you and the facility are taking for clients?
NG: I think I’m holding up OK. My biggest concern is that people are not taking it seriously. I have a master’s in public health, and when this outbreak started I could see where this was going. We have a lack of leadership [in the nation’s highest office] that is making it very hard for people to see how serious this is, and that this is going to get worse before it gets better. The focus, for me, really has to be on providing strong leadership and helping people to understand that social distancing and isolation are truly important right now so we don’t overrun the hospitals.
At the clinic, we have a couple of people on staff who are 60 or over, and we sent them home with pay. We changed our scheduling to reduce the number of people that are in the clinic at one time. We’ve been calling patients ahead of their appointments for screening. We take people’s temperature upon entering the building, and have a staff member do a quick health assessment. We’ve also been putting patients with more urgent care matters at the top of the schedule and rescheduling people who, let’s say, need birth control. While birth control is important, we can walk through options and get refills by telehealth instead of having the patient come to the building. We have our abortion patients whose health care is timely and essential, and we’re not turning them away.
We have a young lady en route from Texas because state officials closed the clinics there. We made an appointment and let her know that we will make sure she will get to and from the clinic safely, and make sure we support her when she gets to the clinic.
Could you speak more to any risks COVID-19 might pose to pregnant people and infants?
NG: Right now, the CDC is saying that pregnant people are not more at risk for getting the virus [than other people]. Of course, to me what’s really important is that pregnant people do their best to quarantine themselves, because we just don’t know how it’s transmitted. I read one article about a baby that was born and had the virus. It’s unclear how the child got it, and whether it was right after delivery or if the mom was a carrier. But for right now, to be safe, the precaution I’m giving to people is to quarantine yourselves in your home, and don’t go out if you don’t have to.
How have the abortion bans sweeping across the South affected your work? How is CHOICES managing during these moments of uncertainty?
NG: We’re a small clinic, but we’re mighty. We just get up and do the work. We educate the community as much as we can about what’s happening, and we always tell them that these doors are and will remain open. We offer a lot of services besides prenatal care and abortion; we have a large transgender clinic with around 200 patients. It’s so important to us that we stay open because I have patients who travel some three hours to get here, which is crazy. This is especially true for transgender patients, who often have limited options in their communities. So we recognize what’s happening, and know that we are in the South, in a space where the [targeted regulations of abortion providers, or TRAP] laws are constant and changing. I think the way we deal with that is we just keep moving forward and doing what we can to keep the clinic open.
After witnessing what happened in Texas, where many of the clinics closed due to the state’s TRAP laws, we knew we had to diversify our services to find other ways to create revenue, so that when the state moves to restrict abortion care, we can keep our doors open while fighting these bad laws. Plus, the community needed these different services.
How do the negative impacts on the rights of people to make choices factor into the maternal mortality crisis?
NG: I met this person who is now a very great friend of mine, Cherisse Scott, who leads SisterReach, a reproductive justice organization here. When we met, she explained the [reproductive justice] model to me, and I thought, “Oh, this makes sense.” We don’t lead single-issue lives; we bring our whole selves to get care. I had to deconstruct my thoughts about health care and decision making, and reconstruct myself through readings of Dorothy Roberts, Loretta Ross, and other folks to better understand how we engage in our health care.
When I decided to do this work and people were like “ it’s an abortion clinic and you’re a midwife,” I pointed out how, historically, midwives also helped people with terminations. And I said that the barriers people are having to access abortion care are the same ones they’re having to access [prenatal] care.
A majority of people [giving birth] here in Tennessee use Medicaid. Because of that, it limits their options in terms of who their providers can be. If people want midwives, their options may be limited because of what insurance will and won’t cover. They can’t have a home birth, or their abortion likely won’t be covered. What we’re seeing in terms of the maternal mortality issue, which has always been there, is that you don’t have true access to care if you can’t make a choice that is best for you.
In addition to the active erosion of bodily autonomy by the Tennessee state government, what other things do you find to be impediments in the social determinants of health for Black, Indigenous, and people of color (BIPOC)?
NG: Poverty’s a big thing here. Another barrier is sexual health education. Tennessee is an abstinence-only state. I didn’t even know what that was, in the beginning, or that there were states that did this. I find that it’s a huge determinant for the high teen pregnancy rate as well as the high sexually transmitted infection (STI) rates we see. They just don’t know about their bodies and how to prevent pregnancies and STIs. And I would say Memphis has to be the first place I’ve lived where there’s this intertwining of religion and just everything. Of course, I grew up in D.C. in a Christian home, but there was still some separation [between religion and health care]. One of the biggest safety-net hospitals is called Christ Community, and the hospitals here are either “Saint Francis” or “Methodist” or “Baptist.” That infusion of religion and faith into education and health care is an issue in moving people forward in being healthier and more proactive in recognizing their own agency [and bodily autonomy].
Additionally, there’s the institutional and systemic racism that is so pervasive in our country. Racism has been in our educational, financial, and health-care systems from the beginning. Our institutions, laws, and culture were built with a bias against Black Americans. This racism contributes to the poor birth outcomes that Black mothers experience.
We are viewed as “less than.” Our pain, our concerns often are ignored. Until we can have these serious conversations about how to address the bias and institutional racism in our health-care system, we will continue to see poor health outcomes in Black communities.
That’s why my work and what we are trying to build at CHOICES is so important. As a Black midwife I choose to center Black and brown families. I choose to value everyone and everyone’s life and lived experience, and recognize that by doing so, I am entering into partnership with them to help improve their lives and the lives of their families.
Can you elaborate on your approach, which you describe as evidence-based holistic care?
NG: The biggest thing is recognizing that people are not what their disease state is, and that holistic care is focused on healing the whole person. Understanding that there’s an interconnectedness between the modern body, spirit, culture, emotions, relationships, environment—all of these things play into your health and your being. And all these things need to be addressed in order to heal people or even to provide them with care.
In my practice, I don’t see Western medicine as the sole answer. I believe there can be an integration of alternative modalities of medicine. At CHOICES, we try to create this strong foundation of care so that it can lead to better health outcomes.
What I try to practice is not having a cookie-cutter idea of treating everybody the same, because everybody is not the same. We can provide holistic, individualized care where we’re caring for each person, truly listening and taking into account their experiences and what their health-care needs are, while using this problem-solving approach. I have some patients who are really into herbal therapy. I’m not an ethnobotanist, but I know enough to provide the information that can help them to find herbs or whatever it is they need.
Or, as another example, I had a hypertensive patient who didn’t want to take medicine, and I wondered about how to address his needs while making sure he stays alive. I learned that he didn’t want to take medicine that would interfere with an important part of his sexual health: sustaining an erection. This is something that would have slipped through the cracks had we just slapped him with blood pressure medicine. This is what I mean by individualized care.
This is probably why my appointments run so long, because I talk in-depth with my patients. With my pregnant patients, our visits are maybe 40 minutes to an hour every time I see them, because we’re talking about nutrition, about their family, about ways to keep them healthy. When we talk about maternal mortality issues in the Black community, we know about things like hemorrhaging, hypertensive crisis, and congenital heart failure. So how do we keep people healthy? To be able to do that I have to have a really good understanding of what’s happening in their day-to-day life. We discuss their activities and their mental state, and make sure we’re healing the whole person.
What do you tell expectant people about their rights with regard to reproductive care? How do you empower people, particularly often overlooked BIPOC, to assert their voice in a clinical setting that can sometimes be unwelcoming to that demographic?
NG: I definitely talk about informed consent, which is really important. We have gotten to this place where we get hospital patients to sign all these papers, and they don’t know half of the things they’re signing, but it gives us a blanket to do whatever we want to do. So I talk to patients about what it is they’re signing and that, at any point, they can take their consent back. You don’t have to consent to everything that’s being done to you. It’s important to ask questions. I tell my patients to come to their appointments with questions written down beforehand because a lot of times, in the moment, you can feel rushed or flustered and you will forget. I tell them not to be afraid to stop people, to tell them slow down if you feel like they’re going too fast. Speak up for yourself and have someone with you.
A lot of the time, especially if you’re in labor, it’s hard to speak for yourself when you’re in pain. A provider can say, “we’ll cut your head off and that will relieve the pain” and you’ll say, “OK, cut my head off, I don’t care” in the moment. So this is why it’s really important to have someone who knows what it is that you want.
With me, before I even touch patients, I always ask for permission. I feel like that’s just the right thing to do. I was in with a patient once and she said to me, “You haven’t asked to check my cervix yet,” and I explained to her that she was not in labor or having contractions, and that is what causes the cervix to open. She said that with her last pregnancy, she was with a different health-care provider, and every week they checked her cervix. I said, “Why would they do that? There’s no point in checking your cervix if it’s not opening up and you’re not having contractions.”
I really encourage patients to say no. It’s a complete sentence.
What are some pathways you see in scaling the community care that CHOICES offers on a national level?
NG: One of the things I’m hopeful about is that people will see what we’re doing, and abortion clinics will see that they can provide more services for their patients other than just abortion. I hope that people can see that providers should be meeting people’s needs, their reproductive health-care needs, whatever they are.
Our hope is that we can scale up and that it will also help to address the stigma people experience in making choices to have an abortion. Even midwifery care is stigmatized. A lot of people won’t share their birth plans with family because having an out-of-hospital birth is seen as different. Maybe we are Stigma-R-Us, right? But really we’re just trying to normalize the idea that people can have choices in terms of their birth, in terms of all their reproductive health-care needs, whether they want to give birth or they don’t want to give birth. Whether they want to parent, don’t want to parent. What we are hoping is that other clinics can see that providing a holistic model of care is realistic.