Midwives and Doulas: A Historical Perspective
I’ve known about the wonderful work Darline Turner has been doing over the years in Austin to help women on bedrest. She now has a new antenatal doula training program as well as a new nonprofit that helps build awareness of the current state of maternal mortality for black women and aims to increase the number of black doulas attending births of black women.
In today’s guest post, Darline shares a bit of history on midwifery and makes a plea for more midwives and doulas, especially those who are people of color.
Black Women are dying. Right here, in these United States, Black women are dying at an alarming three to four times the rate of their white counterparts from childbirth complications. Texas leads the United States-as well as the developed world-in maternal deaths due to childbirth complications. Black women, who make up a mere 11% of the total population in Texas, account for a whopping 29% of the maternal deaths! (1)
It is a travesty, a sin and a shame. In a state as resource rich as Texas, there should be a massive call to action and a coordinated effort mounted to amass resources and to establish a comprehensive maternity care and support system that will care for and nurture not only black childbearing women, but ALL childbearing women!
But this isn’t happening and based on recent legislation, it’s not likely to happen anytime soon. So as a black woman who endured a near death experience during childbirth in Texas-I began hemorrhaging after giving birth to a preterm, low birth weight infant despite having excellent medical insurance and prenatal care-I’m determined to be a part of the fix.
Dating back to biblical times (See Exodus 1:19), the midwifery model of maternity care was the standard of Maternity Care until the early twentieth century. Midwives, women in the community with first aid, herbal and maternity skills tended to all of the childbearing women. In the Southern part of the United States, this was usually a black woman, A “Granny Midwife”. These women were highly respected individuals, pillars in their communities because of their skills, and they ushered in and welcomed each new citizen. They were assisted by women of the community who would come to the laboring woman’s home and share in her care during labor and in the care of her family; caring for the home, preparing food, caring for the other children…These attendants were right there beside their mothers, ssters, daughters, cousins, neighbors and friends providing comfort and support as she brought forth her child and all the women welcomed the new “wee one” into the community fold.(2)
In the early twentieth century, men decided that maternity care was best managed by doctors (men) and that the best place for women to have their babies was in a hospital setting. With the advent of ether anesthesia and penicillin, they justified their opinions based on science and proclaimed that these “uneducated (black) women” were a danger to childbearing women and their communities. Doctors and hospitals began regulating midwifery practice. If a midwife wanted to continue to deliver babies, she had to sit through birthing classes very often taught by men she had brought into the world! She had to take an exam and her herbal treatments were replaced with new mass produced medications. Midwives were required to register with the local health departments and get special licenses to practice. However, once finally admitted into hospitals, midwives were relegated to cleaning rooms, changing beds and doing custodial work, and occasionally assisting at a birth, but not birthing babies as they once had. Many midwives refused to succumb to these practice regulations, so they left the field or retired, as my Great Grandmother Queen Elizabeth Perry Turner did in 1953 after 22 years as a midwife. Before Grandma Elizabeth retired, she said To my Great Aunt Ahleemah, (Currently 96 and her only remaining child),
“Nothing good is going to come of this. They (doctors and hospitals) don’t care about (black) women. Why on earth would anyone want to bring forth their child in a room full of other people (referring to the labor wards set upon hospitals)? And if these same women can’t afford to pay me $5 to deliver their child, what makes anyone think they’ll be able to afford $50? (The fee to deliver in the hospital)(3)
And here we are today in the US, with a maternity system that is highly regulated and constrained, full of technology and yet failing a large population of today’s childbearing women. As midwifery makes a comeback, so is the birth assistant or doula. But today, instead of being the standard of care, midwives and doulas are often health care providers for the affluent because insurance doesn’t typically cover their services. Yet the midwifery model and doulas in particular have been proven to be a critical part of the maternity health care team improving rates of full term pregnancy, reducing rates of infants being born low birth weight, reducing the rates of labor induction, the use of pain medication, instrument assisted (forceps) deliveries and cesarean section deliveries-all at a fraction of the cost of a hospital vaginal birth. Dr. Ellen Hodnett, a Canadian researcher who first reported the efficacy of doulas in her publication “Continuous support for women during childbirth” concluded that,
“Continuous support during labor has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labor and birth.”(4)
The World Health Organization confirmed Hodnett’s findings in its own study utilizing clinical sites in over 230 locations in 29 countries globally. The WHO found that Doulas had such a demonstratively positive outcome on childbirth outcomes worldwide that they recommend,
“Doulas attend all births globally.”(5)
The United States has been slow to adopt this model that has earned wide support globally. As a result, the maternal mortality rate has climbed in the United States since 2002 while it has gone down globally in both industrialized and developing nations. Currently The United States lags far behind its contemporaries in the developed world and even behind many countries with far fewer health resources in the developing world. The Population Institute’s most recent report gives the United States a D- as a nation for reproductive health and rights, while 18 states (of which Texas, my state of residence, is one) earned F’s(6). The countries with the best birth outcomes have health care for all, primarily employ the midwifery model of care for uncomplicated labors and deliveries including the use of doulas, favor the use of fewer interventions during labor and delivery and offer paid parental leave for a smooth family transition. None of these “standards” is close to becoming a national reality anytime soon in the United States, although there is variation in the reimbursement of midwives from state to state, varying use of doulas and varying parental leave programs.
So what can we do to promote the Midwifery Model of Care and increase access to midwives and doulas to all childbearing women in the United States? Well, many of you are already doing it! You are getting trained as doulas and midwives and you are serving childbearing women with much needed support and education. But another glaring disparity exists. Because midwives and doulas are not reimbursed by insurance, they are currently only available to women who can pay for their services out of pocket. The most vulnerable population, black childbearing women, are least likely to give birth with a midwife and/or doula present. Hodnett and the WHO are both clear that the midwifery model of care and the use of doulas are both low cost, highly effective ways to improve birth outcomes and to lower the maternal and infant mortality rates. Still, insurance companies pay out the greatest sums of money to hospitals for neonatal intensive care unit (NICU) stays and to physicians for cesarean sections.
We have our work cut out for us. We are going to have to take the lead in not only serving childbearing women, but educating the general public on the benefits and safety of the midwifery model of care, the benefits of doulas attending childbirths, the safety of home births and advocating and perhaps even lobbying for doulas and midwives to be reimbursed for the health care services that they provide. We also have to do what we can to invite and support more women of color into midwifery and doula care, as black women themselves have stated that they would prefer to have providers who look like them and who share a cultural similarity and understanding. Fellow Doulas, It is time us to be the change that we want to see!
References
- “Maternal Health: Black Women in Texas”. Center For Reproductive Rights. October 2016.
- “THE PERSECUTION AND PROSECUTION OF GRANNY MIDWIVES IN SOUTH CAROLINA, 1900-1940” Alicia D. Bonaparte, Dissertation August 2007 Nashville, Tennessee.
- Oral History from Ahleemah Shakor and County Records, Warren County North Carolina
- “Continous Support for Women During Childbirth (Review)” Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD003766. DOI 10.1002/14651858.CD003766.pub4. Hodnett, ED., Gates, S., Hofmeyr, GJ., Sakala, C.
- “The WHO Safe Childbirth Checklist Implementation Guide-Improving the Quality of Facility-Based Delivery for Mothers and Newborns. The World Health Organization. ISBN 978 92 4 154945 5 (NLM classification: WQ 300)© World Health Organization 2015.
- “The Divided States of Reproductive Health and Rights.” The Population Institute. February 2018.
Darline Turner-BS, MHS, PA-C. Doula. Clinical Exercise Specialist
Darline Turner is the Owner of Darline Turner Enterprises, Inc. Through this parent company, she has founded Mamas on Bedrest & Beyond, a full spectrum doula support, education and resource service for high risk pregnant women.
Answering a recurrent request to share her knowledge of caring for high risk pregnant women, Darline has developed the Mamas on Bedrest Ante Partum Doula Training Program. This comprehensive training program prepares participants to serve high risk pregnant women on bed rest or activity restrictions and to create their own ante partum doula business if they so desire. Learn more about this training program and register for the class starting March 19, 2018 here.
She most recently launched Healing Hands Community Doula Project, a community project to raise awareness of the disparity that exists between black maternal mortality and maternal mortality of women of other cultures. The goal of the project is to effect change at the individual, systems and institutional levels including changing policy and increasing the number of skilled black doulas attending the births of black childbearing women.
