Valuing the Lives of All Mothers
As the American College of Nurse-Midwives (ACNM) continues recognition of the Year of the Nurse and the Midwife, our nation participates in a month-long commemoration of black history. ACNM acknowledges an essential part of our American story, one that offers positive transformation and change through greater understanding. Black History Month reminds us of where we have been as a nation, so we know where we need to go. Today, our country needs to end preventable maternal mortality, a tragedy often fueled by racism and systemic inequality that disproportionately impacts people of color. To broaden the discussion, ACNM invited its state affiliate organizations, the Black Mamas Matter Alliance (BMMA), and the International Confederation of Midwives (ICM) to provide commentary on the issue.
If you are a black woman in America, your risks of dying of a cause related to pregnancy are 3-4 times greater than white women. Other women of color—notably American Indian and Alaska Native—are at a similar risk, but the racial disparities between black women and white women are the most severe. Black History Month reminds us about the critical work that lies ahead in valuing the lives of all mothers equally, eliminating racial disparities, addressing explicit and implicit biases, and making the U.S. a safer and more equitable place to give birth.
This work involves identifying solutions that eliminate the disparities and severely reduce preventable maternal mortality and the inequities undermining positive health outcomes for black mothers and that better integrate certified and licensed midwives into health care systems. Midwives care for women throughout the lifespan. With expertise in both well-woman and gynecologic care, midwives ensure that women and their babies receive a continuum of skilled care before and during pregnancy, during childbirth, and in the important days, weeks, and months following birth.
The United States has the highest rate of maternal mortality in the industrialized world. According to the Centers for Disease Control and Prevention (CDC), approximately 700 American women die every year from pregnancy-related complications. Even more alarming are the significant racial disparities that exist in that black women are 3-4 times more likely to experience a pregnancy-related death than white women, regardless of education, income, or other socioeconomic factors. Furthermore, black women are more likely to experience preventable maternal death when compared to white women, and black women are nearly twice as likely to suffer from life-threatening pregnancy complications including cardiomyopathy, embolism, and eclampsia. The time is now to demand systemic change within our nation’s health care system. We must take deliberate steps to ensure safe and healthy pregnancies and childbirth and increased access to maternal and women’s health providers and improved outcomes for black women and other marginalized communities.
A September 2019 CDC study, based on analysis of national data on pregnancy-related mortality from 2007-2016, found that during this time period a total of 6,765 pregnancy-related deaths occurred in the U.S. Maternal mortality steadily increased with significant racial disparities: 40 deaths per 100,000 births for black women compared to 12 per 100,000 births for white women.
Multiple studies and research demonstrate that a diverse and highly trained certified nurse-midwife (CNM) and certified midwife (CM) workforce, within a team-based care model, offer a viable solution to reducing maternal mortality, increasing access to unbiased high-quality care, addressing nationwide maternity care shortages, and improving maternal and neonatal outcomes. To recognize the vital role that midwives have in transforming health care around the world, the World Health Organization has designated 2020 as the Year of the Nurse and the Midwife. ACNM, BMMA, and ICM together applaud this effort and are committed to supporting the advancement, integration, and sustainability of midwives in the U.S. and throughout the world.
Eliminating the Increased Growth in Racial Disparities: The Work Ahead
The racial inequality impacting black mothers and people of color continues to grow despite ongoing research and frequent calls to take measured steps to address disparities and improve care. While causes are complex and include health insurance coverage gaps, uneven access to services, social determinants of health, and other factors, it is clear that the maternal mortality crisis is rooted in racism and the marginalization of black women and their birth practices. For most black women, that means being exposed to multiple forms of discrimination and institutional barriers to quality care. There is also evidence that the chronic effects of the stress of racism, along with the feeling of not being heard when health concerns are raised, are factors in black maternal mortality and poor maternal health outcomes.
Addressing explicit and implicit bias is an important but often overlooked factor affecting the improvement of maternal health in the United States. There are compelling ethical and human rights reasons to focus our attention toward eliminating the profound and longstanding differences in social conditions that continue to break down along lines of skin color. A multifaceted approach to addressing the U.S. maternity care crisis will require transforming financial and health care systems; ensuring systematic data collection and action based on preventable risk; embracing principles of racial equity and social justice; viewing maternal health holistically and across the lifespan; and building a diverse health care and perinatal workforce that effectively integrates midwifery in the U.S. health care delivery system.
Research has demonstrated that patients respond to health care at a higher degree with providers of the same race or ethnicity. ACNM works to support the practice of midwives by promoting accredited education, research, and advocacy that advances clinical excellence and the expansion of a diverse midwifery workforce. It is committed to advancing legislative and regulatory efforts that seek to eliminate race-based disparities throughout the health care continuum. As a nation we can and must do better in working together to address institutionalized racism, health disparities, and workforce diversity. As the professional association representing CNMs and CMs in the U.S., ACNM stands ready to improve the culture of health for black women and people of color and bring about positive change in our country’s health care system.
ACNM Call to Action
ACNM works at the state and federal level to increase access to midwifery care and supports U.S. policy grounded in the human rights framework that addresses the health inequities impacting black mothers and other women of color and that improves maternal health outcomes overall. Included among them are:
Funding accredited midwifery education programs
With the number of U.S. births projected to be more than 4.4 million by 2050, federal action is needed to dramatically increase the number of high-quality maternity care providers, particularly in rural, underserved, and low resource areas that too often have no obstetrical providers or maternity care services available. Direct funding for accredited midwifery education programs will expand the midwifery workforce while improving racial and ethnic representation within our nation’s maternity care workforce.
The Further Consolidated Appropriations Act of 2020, passed by the House and Senate in December 2019, included a provision allocating $2.5 million in funding under Title VII of the Public Health Service Act’s Scholarships for Disadvantaged Students (SDS) program for the nation’s accredited midwifery education programs. Inclusion of this provision represents a major step toward ACNM’s larger strategic priority of establishing two new permanent federal funding streams under Title VII and Title VIII for accredited midwifery education programs. The Midwives for Maximizing Optimal Maternity Services Act (Midwives for MOMS Act) aims to strengthen and increase much-needed racial and ethnic representation within the midwifery workforce while helping to end the shortage of maternal and women’s health care providers that is contributing to the increase in U.S. maternal mortality and morbidity rates.
The Midwives for MOMS Act will increase the numbers of midwives educated in the United States and will support the education of a more culturally diverse maternity care workforce. Prioritization will be given to programs that seek to increase racial and ethnic representation and those who agree to serve in a Health Professional Shortage Area. Specifically, the bill authorizes $35 million in grants administered by the Health Resources and Services Administration (HRSA) accredited midwifery education programs for:
- Direct support of student midwives;
- Establishment or expansion of an accredited midwifery school or program; and
- Securing, preparing, or providing support for increasing the number of preceptors at clinical training sites to precept students training to become midwives.
ACNM has been working closely with members of the House Maternal Health Caucus to ensure this bill remains a legislative priority in Congress. We encourage all midwives and midwifery supporters to reach out to their House and Senate members about co-sponsoring this unprecedented legislation that prioritizes federal investment in accredited midwifery education programs.
Growing and diversifying the maternity care workforce
ACNM is also working with members of the House Black Maternal Health Caucus to address increasing racial and ethnic representation in the midwifery workforce. The soon to be introduced Perinatal Workforce Act of 2020 would:
- Require the U.S. Department of Health and Human Services to issue guidance to states on how to educate providers and managed care entities on delivering respectful maternal health care and how to recruit and retain maternity care providers from racially and ethnically diverse backgrounds; require the National Institutes of Health to issue a study on best practices in culturally congruent maternity care; and
- Mandate that the Government Accountability Office issue a report on midwifery care in the United States that assesses current barriers to practice and establishes recommendations for how to address said barriers; conducts a state by state analysis of reimbursement rates through Medicaid and private health plans for CNMs, CMs, and CPMs; and provides recommendations around reimbursement for midwifery-led care.
Enhancing maternal health care provided by public health programs
ACNM supports the Birth Access Benefitting Improved Essential Facility Services (BABIES) Act, H.R. 5189, legislation that builds upon the data gleaned from the Strong Start for Mothers and Newborns initiative, an effort by the Centers for Medicare & Medicaid Services (CMS) aimed at reducing preterm births and improving outcomes for newborns and pregnant women. H.R. 5189 would provide planning grants to states to establish a prospective payment system for making Medicaid payments for care rendered by freestanding birth centers participating in the demonstration, including:
- Partial facility payments and facility payments for observation short stays;
- Payments for nitrous oxide and hydrotherapy costs;
- Payments for all health professionals involved in the delivery of care;
- Payments for partial prenatal and postpartum care episodes; and
- Payment for prenatal care only with planned delivery in the hospital.
ACNM supports the Maternal Health Quality Improvement Act of 2019, H.R. 4995, legislation that would:
- Help hospitals and maternity care providers implement clinically proven best practices;
- Increase access to maternity care in rural and underserved areas;
- Eliminate racial and ethnic disparities in maternal health; and support perinatal quality collaboratives.
Eliminating disparities in access to maternal health care
ACNM supports the Helping Medicaid Offer Maternity Services (MOMS) Act, H.R. 4996, legislation that would improve coverage for pregnant and postpartum women enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) by extending coverage for one year postpartum.
Recommendations from ACNM
Additional recommendations and actions to strengthen maternal care in the U.S. include:
- Design a health care system including maternity care that treats all individuals with respect and dignity.
- Support legislation to eliminate roadblocks that reduce accessibility to high-quality midwifery care. Midwives face multiple barriers to practice in the U.S. resulting in reduced access to care, particularly in rural, underserved, and low resource areas. For example, in North Carolina, where 31 of 100 counties do not have an OB-GYN, nurse-midwives must have signed supervisory agreements with a doctor in order to practice.
- Remind policymakers of the need for comprehensive data collection that will lead to evidence-based care and help to reduce racial disparities in maternal mortality.
- Strengthen the utilization of Maternal Mortality Review Committees (MMRCs) to collect data on the factors contributing to maternal deaths to help identify areas for intervention and prevention.
- Establish a mechanism to listen to black women’s experiences during pregnancy and childbirth to identify areas for intervention and prevention.
- Promote education among health professionals that will eliminate unconscious biases and provide more equitable care to patients.
- Educate yourself on the maternal mortality crisis and advocate for respectful, unbiased, high-quality care.
Recommendations from the Black Mamas Matter Alliance (BMMA)
BMMA’s policy agenda centers black women, black birthing people, and their families and is aimed at upholding their reproductive freedom and right to birth justice. Utilizing a reproductive justice framework—one that asserts that all people have the right to bodily autonomy, to determine their own reproductive and birthing experiences, and to parent children with dignity in safe and sustainable communities—helps ensure that proposed recommendations center black women while also promoting their rights and justice. Additionally, BMMA pursues its work knowing that the term “Black Mamas” encompasses a range of people—from birthing people across the African diaspora to those who care for and mother families and communities whether they have themselves given birth or not.
With this in mind, and considering the vast impacts of social determinants on shaping racial disparities in health status and outcomes, Black Mamas Matter Alliance is committed to the following three policy priorities:
- Identifying and ensuring mechanisms for engaging and prioritizing black women and black women led entities in policy and program development and implementation.
While many factors contribute to racial disparities in maternal mortality and morbidity rates, one major area of consideration is to focus on identifying and amplifying the maternity care knowledge, research, and work of black women and black birthing people. Engagement of communities most impacted in crafting policies and programs that shape their ability to thrive is a core human rights principle. Thus, BMMA advocates for greater collaboration with and grant prioritization of black women thought leaders as a critical step to effectively identifying and implementing solutions to reducing maternal mortality and morbidity exacerbated by prolonged exposure to structural racism, gendered discrimination, and bias.
- Establishing equitable systems of care to address racism, obstetric violence, neglect, and abuse.
Existing systems of care have created and perpetuated inequities in health care service delivery and have ultimately resulted in grave disparities in health outcomes. In order to effectively provide care to black women, the U.S. must establish systems of care that are equitable and culturally relevant by acknowledging the value of traditional birthing practices and addressing racism, discrimination, and bias. Black midwives have been a critical piece of the care puzzle for black birthing people in the U.S., but traditional birth work has been systematically degraded as birth has become increasingly medicalized. This marginalization of midwifery and other black research and holistic care knowledge must be undone. As part of this work, and in recognition of WHO’s declaration of 2020 as the Year of the Nurse and the Midwife, BMMA calls on the broader health and health care community to join BMMA in recognizing and uplifting the historical and current birth work of black traditional and community-based midwives who work to address social and cultural issues to help establish equitable systems of care.
- Expanding and protecting meaningful access to quality, affordable, and comprehensive health care coverage, which includes the full spectrum of reproductive and maternal health care services for black women.
Access to comprehensive, affordable reproductive and maternal health services and preventive care is critical to black women’s opportunity to realizing the human right to health. This is accomplished by advocating for and passing maternal health policy that supports the disbursement of financial resources to black-led health care systems and practices and permits insurance coverage and affordability for black women who may search for care outside of typical models.
Recommendations from the International Confederation of Midwives (ICM)
While progress has been made in bridging the gap of inequality and advancing the lives of the black community, some social problems persist, signaling the greater need for culturally sensitive, individualized care delivered by midwives.
The United Nations Population Fund estimates that across the world, the maternal mortality ratio stands at 216 deaths per 100,000 live births. This equates to more than 800 women dying every day while giving life. Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254, 000) of the estimated global maternal deaths in 2017. The high proportion of maternal deaths in certain areas of the world reflects the scale of unequal access to quality health services and midwife-led care. For women in low and middle-income countries, the cost of giving birth is just too high.
This is not only a crisis that exists for women living in these parts of the world. Outside of the developing world, there is another country in which giving birth can cost a woman her life: the United States. The U.S. has the highest rate of maternal and infant mortality in the developed world. Whilst all pregnant women are not immune to the risks of pregnancy related deaths, discussions around maternal mortality increasingly illustrate that black women and women of color are disproportionately impacted by this issue, with black women accounting for 42.4% of deaths per 100,000 live births and 30.4% of deaths affecting American Indian/Alaskan Native non-Hispanic women, in comparison to 13.0% of deaths for their white counterparts. This disparity occurs regardless of education, income or any other socioeconomic factors. The inequalities facing women giving birth are deep-rooted and persist in developing economies facing their own challenges.
In a comparing of the status of women’s health in the U.S. to ten other high-income countries, U.S. women report the least positive experiences among the 11 countries studied. They have the greatest burden of chronic illness, highest rates of foregoing needed health care because of cost, greatest difficulty affording health care, and are least satisfied with their care. Although not specific to race or colour, women’s satisfaction of care is a high indicator of quality of care.
The 2018 WHO publication, “Intrapartum Care for a positive childbirth experience” recognizes a “positive childbirth experience” as a significant end point for all women undergoing labour. It defines a positive childbirth experience as one that fulfills or exceeds a woman’s prior personal and sociocultural beliefs and expectations, including giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of practical and emotional support from a birth companion(s) and kind, technically competent clinical staff. It is based on the premise that most women want a physiological labour and birth and to have a sense of personal achievement and control through involvement in decision-making, even when medical interventions are needed or wanted.
As defined in in the Lancet 2014 series on the Power of Midwifery, midwifery is “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants, and families across the continuum throughout pre-pregnancy, pregnancy, birth, post-partum, and the early weeks of life.” Midwifery includes family planning and the provision of reproductive health services. The services provided by midwives are best delivered not only in hospital settings but also in communities—midwifery is not a vertical service offered as a narrow segment of the health system. Midwifery services are a core part of universal health.
For black women, who have the highest rate of infant and newborn deaths of any racial or ethnic group in the U.S., it is evident that the causes of racial disparities in maternal mortality can have varying policy outcomes that are often difficult to isolate due to their interlinked and complex nature. As a result, activists, academics, and civil society professionals have called for the U.S. government to take greater action in ensuring safe births for all women through the implementation of targeted efforts that address barriers to accessing better maternal health services, as well as the creation of programs that are culturally responsive and enhance the experiences of birth for black women in America.
The trends in maternal mortality rates in the U.S. cannot be solely explained by the gap between the rich and the poor. These racial inequities can be improved by economic empowerment, but any solution to this pressing injustice must be comprehensive, choice-focused, and culturally relevant for black women within the U.S. Improving access to midwifery care is central to promoting birthing choice and reproductive autonomy for low-income women and women of color. With midwives offering the highest quality, women-centered care, the global shortage of midwives needs to be addressed if equal access to midwife-led care is to be realized.
In order for the United States’ standards for maternal and infant mortality to meet those of the rest of the developed world, health care providers and policymakers must work together to ensure that midwives have access to a functioning health care system that enables them to provide safe, woman-centered care underpinned by evidence-based research. Additionally, greater efforts must be made to integrate research, education, and the country’s health service system to ensure that existing primary health care strategies enhance the quality, accessibility, and impartiality of maternal and newborn health across all communities. The body of evidence and statistical data on racial disparities in maternal mortality in the U.S. illustrates the need for proactive legislation that not only gives a comprehensive overview of this issue but transforms the quality of care received by black women and women of color. This is particularly pertinent in supporting the development of a comprehensive policy framework aimed at eliminating racial inequalities in maternal and newborn health.
ACNM Affiliate Organizations Creating Positive Change at the Local Level
ACNM’s state affiliate organizations are reaching deep into their local communities to tackle racial inequities and health care disparities. Examples of their recent work include:
California State Affiliate
ACNM’s California affiliate worked collaboratively with Black Women for Wellness to co-sponsor and advocate for the successful passage of the California Dignity in Pregnancy and Childbirth Act – SB 464 in October 2019. The legislation aims to decrease the disproportionately high rates of black maternal mortality by making it mandatory for health care providers who serve pregnant women to obtain implicit bias training. The bill also makes California’s data collection of pregnancy-related deaths more robust. The affiliate has also established a Reproductive Justice and Anti-Racism Advisory Group, which will serve in an advisory capacity and help ensure the affiliate’s policies and work will serve to increase racial equity. Additionally, it took steps to highlight the topic of racial bias in all aspects of its annual meeting, hosted a staff anti-racism training program, and updated its bylaws to ensure a culture of inclusivity within the organization. Among its current advocacy efforts is the effort to introduce and pass legislation that would eliminate the need for physician supervision of a midwife, which would enhance a woman’s access to quality health care and reduce racial disparities.
District of Columbia Affiliate
In 2019, ACNM’s D.C. affiliate hosted its second-annual Miles for Midwives, a 5K run/walk to raise awareness of the maternal mortality crisis in D.C. and highlight organizations working to address this crisis. The run raised $20,000, which was donated to Mamatoto Village, an organization that supports pregnant people of color and their families. In 2018, the D.C. City Council approved a maternal mortality review committee. The D.C. affiliate was actively involved in the passing of the bill, successfully advocating for designated positions on the committee for midwives. This newly formed committee includes four CNMs. The D.C. affiliate recently hosted a bias training for members, led by Reframe Health and Justice, to engage and learn about their own biases, anti-racism work, and how to grow as an affiliate around the principles of anti-racism.
New Jersey State Affiliate
ACNM’s New Jersey affiliate works closely with the state’s First Lady, Tammy Murphy, on her Nurture NJ statewide effort to reduce maternal and infant mortality and morbidity and ensure equitable maternal and infant care among women and children of all races and ethnicities in New Jersey. The state has established a Maternal Mortality Review Committee to annually review and report on rates and causes of maternal mortality and morbidity in New Jersey, and to recommend improvements in maternal care. Two midwives, one representing ACNM, will participate on the committee.
Georgia State Affiliate
ACNM’s Georgia affiliate participates in an array of initiatives designed to eliminate racial disparities and improve maternal and newborn health outcomes. This includes:
- Representing of two CNMs in the state’s Maternal Mortality Review Committee.
- Testifying in hearings about the racial disparities impacting maternal health outcomes in the state and educating the public and policymakers about the value of the midwifery profession in reducing maternal mortality; advancing legislation to expand postpartum Medicaid; advocating for the advancement of the Georgia Dignity in Pregnancy and Childbirth Act (HB 745), legislation that would require perinatal facilities in the state to implement evidence-based implicit bias programs for its health care professionals and compile and track data on severe maternal morbidity and pregnancy-related deaths.
- Working to establish an emergency fund to help support midwifery students of all races and ethnicities.
- Collaborating with local organizations and stakeholders such as the Georgia Perinatal Quality Collaborative to develop statewide perinatal data and quality improvement practices that will strengthen health outcomes for mothers and newborns while addressing the issue of racial disparities in the state. The Georgia affiliate partners with the Doula program to provide much needed service to underserved groups in Atlanta, and also works with the Atlanta Birth Center and Healthy Mothers and Healthy Babies.
Illinois State Affiliate
In Illinois, the inspirational leadership of a single CNM led to the establishment of a new organization to help address the disparity in the number of midwives of color. Melanated Midwives aims to diversify the midwifery profession, provide care to the most vulnerable populations, and assist in decreasing the infant and maternal mortality rates. The new organization provides student midwives of color with financial support, through two annual scholarships, and organizational mentorship.
Kentucky State Affiliate
ACNM’s Kentucky affiliate is advocating for critical legislation, AN ACT Relating to Free-standing Alternative Birthing Centers (HB 311), that would exempt freestanding birth centers from requiring a certificate of need. Eliminating this requirement would allow birth centers to operate in the state, enabling them to provide high-quality, evidence-based maternal health care to women from rural, underserved, and racially and ethnically diverse communities.
Michigan State Affiliate
ACNM’s Michigan affiliate supports Metro Detroit Midwives of Color (MDMOC), a local non-profit professional organization, inclusive of all minority midwives that serve women in the Metro Detroit area. The group works to improve the racial diversity within the midwifery community by offering mentorship and support to aspiring midwives of color. In the past two years they have given away a small number of scholarships for women of color to help reduce the financial burden of midwifery education. In 2020, the Michigan affiliate will launch and sponsor an annual scholarship through MDMOC that will help finance a student midwife’s education as well as pay for a year-long membership to ACNM and attendance at the affiliate’s Winter Retreat education and networking event.
Oregon State Affiliate
ACNM’s Oregon affiliate was instrumental in supporting the appointment of a midwife to the board of Oregon’s newly formed maternal mortality review board. The establishment of this board will help to collect data needed to reduce racial disparities in maternal mortality. Other initiatives include working with the A.C.N.M. Foundation to create several scholarships for student midwives of color; sponsoring a podcast, Midwifing America, which promotes midwifery as a solution to meeting maternal and women’s health care needs and that addresses racial and other health care disparities; and the formation of a Diversity, Equity, and Inclusion Committee which hosted a study group to discuss Layla Saad’s Me and White Supremacy Workbook and how the messages in the book can help to stop racial behaviors that inflict damage on people of color.
ACNM is the professional association that represents Certified Nurse-Midwives and Certified Midwives in the U.S. and is dedicated to research, education, and advocacy to advance the well-being of mothers and infants through the midwifery profession. Members are primary care providers for women throughout the lifespan, with a special emphasis on pregnancy, childbirth, gynecologic and reproductive health. The College sets the standard for excellence in midwifery education and practice in the U.S. while also strengthening the capacity of midwives in developing countries.
BMMA functions as an alliance of Black Women-led entities operating at the national, state, and local levels that center Black women, and whose activities are guided by the birth justice, reproductive justice, and human rights frameworks. As a national network we advocate, drive research, build power, and shift culture for Black maternal health, rights, and justice. We envision a world where Black mamas have the rights, respect, and resources to thrive before, during, and after pregnancy.
ICM is an accredited non-governmental organization that supports, represents and works to strengthen professional associations of midwives throughout the world. There are currently 140 members associations, representing 121 countries across every continent.