Abstract
Introduction:
Black midwifery practice leaders are reimagining perinatal care for Black women and birthing people by designing and implementing innovative culturally affirming community models of care. They possess a unique lens on the factors that sustain and threaten their innovative work. The aim of this study was to explore Black midwives’ perspectives on the components of these models of care, their leadership experiences, and facilitators and barriers of scaling these models for maximal impact for Black women and birthing people throughout the United States.
Methods:
We purposively identified and conducted in-depth semi-structured interviews with Black midwifery leaders (i.e., founders, directors, owners of Black-led community-centered midwifery practices). We interviewed nine participants including certified nurse-midwives (n = 7) and direct entry midwives (n = 2) between September 2023 and July 2024.
Results:
We identified four themes: (1) Reclaiming a legacy of care and safety: the incorporation of ancestral traditions and culturally holistic practices to create responsive models of care; (2) Scaling up: the urgent need for more Black midwives and culturally safe educational and professional development pathways; (3) Scaling out: the necessary policy and infrastructure reforms, particularly reimbursement reform and regulatory integration; and (4) Scaling deep: the importance of transformative cultural norms and solidarity-based relationships.
Conclusion:
Black midwives lay out a vision of how their reimagining can be scaled nationally. Their suggestions span broader structural changes relevant to all midwives, while also identifying potential solutions specific to the needs of Black midwives, who face both racism and hostility toward the practice of midwifery.
Introduction
“The only people who care enough about us to work consistently for our liberation is us. Our politics evolve from a healthy love for ourselves, our sisters and our community which allows us to continue our struggle and work.”
Combahee River Collective 1977. 1
Black midwives have long played a central role to the health and well-being of Black families in the United States as primary birth attendants, trusted health experts, keepers of traditional knowledge, and community leaders.2–4 Despite their essential role, Black midwives were systematically marginalized in the early 20th century alongside the rise of obstetrics as the dominant care model.2,3,5,6 Although 13% of birthing people are Black, only 8.7% of Certified Nurse Midwives/Certified Midwives (CNMs/CMs) in the United States are Black, highlighting the lasting effects of midwifery’s marginalization. 7 a Despite this underrepresentation, Black midwives are reimagining perinatal care by designing and implementing culturally affirming and community-centered midwifery models that promote Black patients’ safety through evidence-based care and mutual trust-based relationships.8–10
The 21-point Black Midwives Care Model©, authored by Jamarah Amani, co-founder of the National Black Midwives’ Alliance, formally articulates core elements of Black midwifery care. 11 The Care Model outlines 21 points categorized into seven overarching domains: honoring racial identity, providing holistic and culturally grounded practice, facilitating shared decision-making, protecting bodily autonomy, cultivating community accountability, and upholding reproductive justice. 11 A growing and diverse landscape of Black midwifery models operationalize many of these elements. Some models are profiled in the literature, like the group-based prenatal models of Beloved Black Birth Centering 12 and the Melanated Midwives, 13 or birth center models, like the Roots Community Birth Center. 14 These models vary in scope, structure, and service design but are united by shared commitments to culturally affirming care, community accountability, and advancing reproductive justice and autonomy for Black birthing people. However, these models do not exist at scale, limiting their availability to Black women and birthing people nationwide.
There have been calls to grow and scale Black-led community models to achieve national perinatal health equity. 15 Health equity “means that everyone has a fair and just opportunity to be as healthy as possible” 16 and achieving it for the larger population requires scaling- or model growth and spread. The concept of scaling for social innovation provides a useful tripartite framework- scaling out, scaling up, and scaling deep- for understanding how models can grow and spread. 17 Scaling out requires an increase in the number of resources available to deliver an innovative model broadly. Scaling up concerns changing policies and regulations to facilitate innovation spread. Scaling deep focuses on growing the impact of the model over time by promoting transformative cultural change and relationships. 17
Scaling midwifery to improve maternal health has been previously identified as a global priority, 18 however, little research has examined how Black-led midwifery models of care may scale within the United States maternal health system. 19 Thus, our study aimed to explore Black midwifery leaders’ perceptions of the facilitators and barriers to scaling these models of care. Midwifery leaders shared their insights on the key components of these models as well as their vision for achieving scaling and sustainability over time. Examining what is required to scale Black-led midwifery models is critical to understanding how perinatal health care systems might shift to value and sustain culturally affirming community-led models of care.
Methods
Study design
We conducted semi-structured interviews with nine Black midwives in leadership positions at Black-led community midwifery practices that primarily serve Black birthing people. We utilized the Standards for Reporting Qualitative Research (SRQR) checklist 20 to guide the conduct and reporting of the study (see Supplementary Data). The Johns Hopkins University School of Medicine Institutional Review Board (IRB) deemed this study exempt (#00382253).
The study team
The lead author and principal investigator (PI), N.K.J., is a CNM and former community and birth center midwife with a PhD and over 8 years of experience in qualitative research. N.K.J. is a Black, cisgender woman who became a CNM in 2012. The research team also consisted of a research coordinator (S.T.W.) and a research assistant (Y.T.), both of whom were MSPH graduate students at the time of data collection and initial data analysis. The research coordinator (S.T.W.) is a biracial, cisgender woman and trained birth doula with 3 years of qualitative research experience. S.T.W. conducted five of the interviews, coding and analysis. Y.T. is a Black, cisgender woman with 4 years of qualitative research experience. Y.T. participated in coding interviews and data analysis.
The PI trained and supported both junior study team members in qualitative interviewing, coding, and analyses processes. The PI, as a former community midwife, has professional contacts with some participants. Neither of the study team members had prior relationships with participants, but both had an interest in midwifery, a fact made known to participants. Our team remained attentive to positionality, being mindful of the PI’s professional experience and the trainees’ interest in midwifery, and engaged in reflexivity throughout the research process.
Theoretical framework
In this analysis we examine Black midwifery leaders’ perspectives through a Black feminist lens. 21 The central tenet of Black feminism is that Black women have a unique point of view of the world, because their lived experiences are shaped by intersecting oppressions such as race, gender, class, ableism and more.22,23 Black women are often subject to harmful stereotypes that diminish their humanity and agency. Black women are blamed 24 for their own poor health outcomes when, in reality, the “black maternal health crisis” is a structural failure. 25 The perinatal health system, like all societal structures, is undergirded by White supremacy, 26 and designed to fail and dehumanize Black women. Black feminism is an appropriate anchoring framework for this study because it does not accept that Black women are only seen through a deficit lens, as a crisis or a problem. Black feminism identifies the underlying structural violence and posits that the solutions to maternal health inequities must come from Black women themselves as they dismantle the conditions that devalue Black women and birthing people’s lives and instead create care systems that affirm dignity, safety, and wholeness.1,27
Sampling and recruitment
Participants were eligible for the study if they identified as Black or African American, were 18 years old or older, held any midwifery training credential (e.g., Direct Entry Midwife, Traditional Midwife, Certified Professional Midwife, Certified Nurse Midwife, Certified Midwife), and served as a leader (e.g., director, deputy director, founder) in a United States community midwifery practice primarily serving Black individuals. In this study, community midwifery was defined as midwifery-led care in a setting outside of the hospital inpatient setting including clinic, home, birth center, or mobile motor vehicle. While participants could also provide inpatient hospital-based care, some component of their practice had to be situated outside the hospital inpatient environment. We recruited participants through emails, list-servs, snowballing and word of mouth.
Data collection
We conducted interviews on the Zoom videoconferencing application between September 2023 and July 2024. We used an oral consent process before the interview started, in which a study team member read the consent form and information sheet with the participants and answered any questions. Interviews lasted between 45 and 68 min. We used a semistructured interview guide developed from the research aims after review of the relevant literature (see Supplementary Data). Interviewers began the interview by asking participants to describe their perceptions of community-centered midwifery care. Additional questions inquired about their leadership experiences, perceptions of facilitators and barriers to sustainable and successful community-centered midwifery practice, factors that impact the scaling up of these practices, and their own personal experience of burnout and self-care. We stopped recruiting new participants once data saturation was achieved and no new ideas or concepts were raised by subsequent participants. We assessed saturation through ongoing team-based review of transcripts, including multiple consensus meetings. Following these meetings and several subsequent interviews in which we found that there was both a redundancy of concept and no new themes emerging, we determined that saturation had been reached. We also deemed the final sample appropriate, given that the study focused on a narrowly defined and highly specific population: Black midwifery leaders of Black-led and community-centered midwifery models of care serving Black individuals. The final sample reflects both the limited number of individuals nationally who occupy these leadership roles and the structural barriers shaping and limiting the widespread existence of these models of care. Participants received a $50 electronic gift card as a thank you for their time and expertise.
Analysis
A professional transcription service transcribed each interview. We used NVIVO version 20 to code the transcripts. We used an inductive and deductive analytic approach. Author N.K.J. created a preliminary codebook through a deductive approach based on the initial research questions. N.K.J. and S.T.W. expanded on this preliminary codebook through an open inductive approach of three interviews to allow flexibility to explore novel concepts raised by participants. 28 The final codebook was then applied by authors S.T.W. and Y.T. to the remaining interviews. Y.T. and S.T.W. met after coding each interview to discuss discrepancies and improve consistency in coding. Interviews were analyzed by each member of the research team then examined using comparative analyses to identify patterns in the data. We used the scaling for social innovations framework 17 as an analytic guide and employed thematic analysis to identify key themes.29,30 We also used Black feminism to guide our data analysis procedures, ensuring that we interrogated intersecting oppressive structures, resisted deficit-based framings, and emphasized agency. Codes were grouped together into thematic categories. Final key themes were agreed upon by all research team members after the completion of coding and comparative analysis. We enhanced trustworthiness by incorporating strategies such as reflexivity, including intentional reflection and examination of each study members’ potential for bias, utilizing a systematic coding process, keeping a detailed audit trail of coding and theme decisions, team consensus, and utilizing rich, thick description of context and participants. 31
Results
Participant demographics
The participants consisted of nine midwifery leaders aged 40–65 who self-identified as Black (see Table 1). The mean length of practicing as a midwife was 14.4 years. Most participants live in the South (n = 6), while others live in the West (n = 2) and the Midwest (n = 1). Participants included Certified Nurse Midwives (n = 7) and Certified Professional Midwives (n = 2).
Participant Demographic and Professional Characteristics (n = 9)
Midwives could report more than one practice setting if applicable.
Themes
We identified four themes: (1) reclaiming a legacy of care and safety; (2) scaling up—more black midwives; (3) scaling out—reimbursement and policy reform; and 4) scaling deep—cultivating culture change and transformative relationships. Themes are presented below along with exemplar quotes. Facilitators identified by Black midwives for scaling of Black-led midwifery models of care are summarized graphically in Figure 1.
Factors influencing scaling of Black-Led midwifery models of care.
Reclaiming a legacy of care and safety
The contemporary practice of Black midwifery is a purposefully designed reclamation of what it means to provide care and ensure safety for Black birthing people.
Legacy
A deep calling to continue the legacy of Black midwifery in the United States was both an initial source of inspiration to pursue midwifery for many participants and an ongoing influence on how they approach their work. Black midwifery leaders communicated a desire to honor the rich legacy of Black midwifery in the United States, recalling a period in which Black midwives were trusted and endeared by their communities. This direct entry Southern midwife shared that the Black midwives that came before her continue to guide her: “I recognize that this is ancestral work and that my ancestor midwives walk with me…Having the clinical knowledge is important for sure, but also having that connection to spirit, to ancestors, to something greater than yourself is an open channel of intuition. You might see things that aren’t showing up on a blood pressure or a Doppler, but you have a sense… there’s something that speaks to you that is beyond the numbers [and it helps to] prevent a complication or it opens an area of dialogue with a client so that they leave feeling like, ‘Oh wow, she really understood me.’”
Designed for Black women and birthing people
Black community midwifery is intentionally and creatively designed with Black people at the forefront and in the center. This is a necessary corrective to combat the historical neglect, exploitation, and ongoing disparities Black women and birthing people face. As one homebirth midwife and practice owner explained, “Quite frankly, it means Black first. All humans deserve good things, but given our history in this country, Black humans in this country really need a lot more support.”
Prioritizing racial and cultural concordance
Building clinical teams that are predominantly, or exclusively, Black is a critical part of creating an environment in which there is shared purpose, intention, and community centered on Black racial identity. This participant describes why she intentionally built a mostly Black team, “I’ve tried to build a team that has the passion and intentionality about caring for this community. There’s so many things that I don’t have to explain or get them to understand. They get it.”
Holistic care in context
To fully address a patient’s clinical needs, Black midwifery leaders extoll the importance of understanding how the individual exists within their wider life context. Midwives commented on the role of community disinvestment, structural racism and negative social determinants of health; noting that their perinatal care models are designed to meet these larger contextual needs. This homebirth midwife shared: “When you’re providing the care, you’re not just thinking about what’s going on in the birthing person’s body, but what is that community that they live in and how does that interface with the care that we provide at the clinic?”
Determining community needs proceeded in both informal and formal ways. Patient visits or informal brief encounters provide valuable information to understand community-defined priorities. However, some leaders took more formal approaches using surveys and focus groups to collect information to inform their model design and/or evaluate and adapt their services. This homebirth/birth center midwife shared that her practice conducts a community assessment to determine what services to provide: “Providing community-based midwifery care really means meeting people where they’re at and understanding the needs of the community, understanding the history of the community, a little bit of the landscape and why things are the way they are, what services are available, what services are not, whether it’s a food desert or a transportation desert. We look at zip codes to see what the maternal infant health outcomes are and then tailor our services to those communities that need us the most.”
Designing creatively
Participants describe designing creatively alongside communities, building on community-defined visions of care, and nurturing and partnering with existing community assets while addressing barriers and gaps in their local health care systems. Designing creatively sometimes meant partnering with individual community practitioners or community organizations providing much-needed complementary services. One participant shared her experience leveraging grant funds to provide services not readily available in her health care system: “In our model we’re not just going to tell people. ‘Eat more vegetables and exercise.’ [We said]…Oh, my gosh, there’s this amazing Black woman, mother, personal trainer providing fitness classes. Let’s contract with her and have her come into the clinic space and provide these classes after our group visits.’ I pay her out of grant funds that we raise so that she can provide the fitness classes that are part of our package. Our health system never would have employed a personal trainer or be paying a personal trainer. They would just tell you to exercise more and then my patients would be like, ‘Well, how and where?’”
Designing creatively means building alternate care pathways that challenge the dominant care structures. This midwife shared: “When we say medical industrial complex, I don’t think people really determine what that actually is. I feel at this point, it’s essential to understand what it is so that you can then figure out a way literally to circumvent it. That’s what I did. I’m circumventing a system.”
It also meant designing freely without being initially certain of the outcome: “I think that one of the things that most people are afraid of is failure. I’m not afraid of that. I think what works really well is the ability to imagine and not be afraid. You can’t do this work and be afraid and play it safe. I haven’t done that, thrown everything at the wall.”
Reclaiming safety
Black midwifery leaders endeavor to create a model of care that their clients perceive as safe. Participants noted that alongside the growing awareness of inequities in perinatal health, many clients increasingly see hospitals as inherently dangerous places. Black community midwifery care can be a refuge for patients whose concerns about experiencing racism and neglectful perinatal care influence their decisions about birth setting and birth providers.
Safety was not always defined solely physical or clinical terms. One midwife described how she designed a homebirth practice space that feels “like family” and is free from the need to codeswitch—or change how one speaks or acts to be accepted, a common strategy that Black individuals use when interacting with others of a different race. This participant further explained: “[My practice] is a safe space. You can come into my office, and it is not clinical. It’s not sterile. One of my [patient’s partners] said ‘coming here is like coming to my auntie’s house. It’s not like us coming to the doctor’s office.’”
Scaling up—Nurturing more Black midwives
More Black midwives
Black midwifery leaders proclaimed an urgent need for more Black midwives, noting the dearth of Black midwives across the United States as a barrier to achieving perinatal equity. “We already have a huge problem with nurse-midwifery being over 90% white. If we have a midwifery profession over 90% white, we are in no way poised to address racism-based disparities. We know we need to get our midwifery profession to be able to represent the communities we’re serving, all the Black and brown and Indigenous folks we’re serving that do not have the representation of midwives that they need.”
In addition to calling for more Black midwives, participants emphasized the need for culturally affirming educational and professional development spaces where midwifery students and new midwives could grow, to counteract the harms and racism encountered in educational and clinical work settings. Creating such spaces was seen as essential to both increasing and sustaining the number of Black midwives. Participants described the challenges to creating more midwives as multilayered but highlighted the role of racism perpetrated by faculty and clinical preceptors as a major challenge. Many perceived the lack of midwifery education program at historically Black colleges and universisities (HBCUs) as a barrier: “We don’t have any midwifery programs at HBCUs right now.”
Lack of affordability was also cited as a barrier to accessible midwifery education for Black students. One midwife noted the shift in midwifery education programs from master’s to doctoral programs, cautioning that such changes may disadvantage students who need an accessible and affordable pathway into the profession. These changes often occur alongside similar shifts in nursing schools where many midwifery programs are housed, making them subject to trends in nursing education. She explained: “When we think about what needs to happen in the future to support more community-based midwifery, we need to be able to educate midwives. Right now, it’s in shambles across the country. The university I went to get my master’s in nurse–midwifery is moving toward a DNP entry program. That’s crazy talk. A DNP does not improve somebody’s clinical practice… For a DNP to be the minimum entry degree, that’s going to be a barrier. The education is going to be even more expensive. It already is way too expensive. It’s going to exclude more and more people.”
Intersecting oppressions: Misogynoir and the marginalization of midwifery
For Black midwifery leaders, burnout stems not only from the physical and emotional demands of the profession but also from contending with racism and hostility toward midwifery. Participants noted that the high rates of burnout and attrition within the first few years of practice stifles the growth of the profession nationally. Midwifery, as a relational model of care, is inherently energy-intensive, requiring sustained emotional, physical, and cognitive engagement regardless of the setting. However, participants who lead models in large health care institutions noted the pervasive way that racism, white supremacy and misogynoir impacted their leadership experience. One participant summarized these assaults as “the undertones, the microaggressions, the paternalism.” Another participant shared her experience contending with the multiple threats to her role as a Black midwifery leader: “It’s hard to work within the system and try to lead these kinds of innovations and culture changes and also being Black at the same time and being a midwife at the same time, both of which are historically marginalized and discriminated against identities in a health system.”
Healing practices emerged as critical tools for survival and renewal in the face of the resulting burnout and stress. Midwives described leaning on spiritual practices, therapy, asking for help, taking walks, meditating, fellowshipping with other midwives, and being intentional about proactively addressing their health needs as a way to care for themselves while leading. Still, participants rejected the notion that burnout could be solved through individual actions alone. They situated burnout within larger structural factors that would need to be addressed in order to successfully scale Black-led midwifery models in a sustainable way. As one participant reflected: “How do you scale up the workforce to be reflective of the communities that need them? We have some data that just came out that said midwives are burning out within the first five years of practice. I think it’s because they’re tired. They’re tired of fighting and midwives can burn out fast. I think that scaling up is going to involve really addressing fostering some support for the workforce to maintain it because you can get people in, but we got them going out just as fast as we can get them in, so we can’t grow.”
Participants noted that other Black midwives, especially those early in practice, face interconnected stressors and need assistance navigating them. Culturally affirming Black midwifery fellowships that provide structured training and support for newly licensed midwives could play a role in better equipping newly licensed Black midwives to weather the multifaceted challenges that might lead to early career attrition. As X expressed: “They need to be founded in Black feminist thought primarily at sites that utilize reproductive justice framework focused on community-based care, working to channel Black granny midwifery. They would include self-care and racism recovery. Racism recovery specifically addresses challenges around internalized racism, surviving systems of oppression, built-in professional development and leadership, and entrepreneurial training.”
Scaling out—reimbursement and policy
Participants described reimbursement and policy changes necessary to scale Black-led midwifery models of care.
Reimbursement
Reimbursement reform was most frequently cited as critical to sustain and scale Black-led midwifery practices. Losing money on births due to low payer reimbursement was identified as a common occurrence that threatened the viability of their work. One participant shared: “Current payer models with insurance cannot make the math. It just won’t math right. You’re always going to be running at a deficit.” Participants practicing at birth centers noted the importance of payer reform for birth center care, citing the low or denied facility fees. One birth center midwife shared: “One thing that could be fixed is how much we get reimbursed for when folks deliver in the birth center, those reimbursement rates.”
Another participant shared that scaling up will require new reimbursement models that incentivize innovation and the use of underutilized but evidence-based models: “[My state] is doing the most centering care of any state in the country, but we don’t have that enhanced reimbursement. This is just one example from a big-picture policy level. We could be doing better to recognize and incentivize systems wiling to shift and practice evidence-based models of care like midwifery-led Centering Pregnancy care, but we have to have a guide like a how-to.”
Furthermore, midwives noted the limitations in payer models that only focus on the provision of clinical care, rather than on addressing comprehensive social needs that influence outcomes. “The midwifery model of care is about holistic wellness and it’s about preventative care. Particularly, if we want to be eliminating the racism-based disparities that we’re seeing…we’ve got to be taking a whole-person preventative care approach. That means thinking about all the aspects of wellness, food, nutrition, exercise, environmental safety. All of these things are so important. Payers are slowly coming around, I think, to recognizing that and providing reimbursement models to cover those kinds of things, but there’s still a long way to go.”
One participant called for catalytic investment and resource mobilization, of the type seen during the early COVID response: “Operationalizing midwifery means doing the same thing you did when COVID showed up and, ‘Oh, let’s get these community health workers out.’ All kinds of money showed up. No crying, no arguing. ‘Oh, we need community health workers.’ And… ‘Oh, we need to fill the stadium. They’re giving shots over there. Get the people mobilized.’ And… ‘Oh, let’s build a hospital in the parking lot’…Suddenly, we had an infrastructure out of nowhere.”
Policy
Midwives, particularly those in Southern states, remarked on the need for greater state and federal policy integration to improve their ability to practice full scope midwifery. Participants noted that state regulations that precluded independent practice trickled down to the hospital level and impacted the ability of midwives to practice fully by restricting admitting privileges or excluding them from the same privileging categories as physicians. “From the policy level…the regulations on midwifery practice—particularly in Southern states is a barrier. We know that the outcomes are really bad down here, and we have some of the most restrictive practice policies on the books. If you look out West and up North, there are some states where midwives can practice independently and, in those states, the outcomes are better. These restrictions limit how we practice, including preventing us from having admitting privileges.
Midwives cited the importance of educating policymakers, pointing to a widespread lack of awareness of the profession. They expressed concern that the current policy landscape focused almost exclusively on doulas, while midwifery legislation at both state and federal levels languished. Many attributed this focus on doulas to a lack of understanding about midwifery. This participant shared an encounter that underscored this gap, noting how the lack of knowledge about midwifery had tangible effects on policy and funding. “There is a big initiative in our state that is responsible for deciding what kinds of initiatives should be funded to address this problem of racism-based disparities. These folks of all folks controlling state-level funds should understand the lay of the land and what are the evidence-based strategies. These people barely know the difference between midwives and doulas. I talked to someone responsible for making decisions about what to fund. He was like, ‘Oh, midwifery. Isn’t that new? Doulas are getting more funding because that’s an older profession, right? Midwives, that’s like a new innovation. That’s why we put it in the innovation category because it’s brand new.’ I was like, ‘Oh, my God. It’s only the oldest profession in the whole entire world.’”
Scaling deep—culture change, relationships
Scaling deep requires culture change and deep relationships. Among the culture changes identified as necessary were those related to affirming women’s autonomy, advancing reproductive freedom, and elevating the social acceptance and value of midwifery. One participant noted how within their state, two cities only three hours apart had starkly different cultures of midwifery, shaping the acceptance of midwifery within the larger perinatal health system: “A nearby city has a large university medical center with a midwifery program. I think that this medical center is extremely powerful in that city and that midwifery program really has acted as an anchor for midwifery in that community. It’s been in that community now so long it’s just become a part of the community. The university medical center also has a birth center. There’s only two birth centers in this state. Theirs and ours. I think that their birth center has helped to normalize midwifery in that community. I think that’s why it’s different.”
Black midwives noted that cultivating relationships with those in solidarity to their vision—patients, community members, other midwives, physicians, organizations—was critical to sustaining and strengthening their work. These mutual relationships were reflected when patients partnered with midwives in advocacy: “We’ve had several of our clients, our mamas, get involved and either attend our doula training and become part of the workforce or become an advocacy person and go with us to [the state capitol] to talk about the importance of these services.”
Collaboration with other Black-led organizations empowered midwives to take collective action to advance Black midwifery and maternal health: “Most of our support has come from collaborations with reproductive justice groups like Black-led midwifery associations, advocacy and research organizations. I do think that having those partnerships has been really critical to our mission to show up as a community center.”
A homebirth practice owner shared similar sentiments about her volunteer work with the national organization representing Black midwives: “I’m also very active with the National Black Midwives Alliance, which is a program housed under SBJN [Southern Birth Justice Network]. And that is really, for me, important to protect the interests of black midwives in our country because we were attacked, we were eradicated, but no one is going to save us. No one cares about black maternal health. And so by preserving that legacy and supporting the strength of Black midwives, we can take care of our own and work toward changing the negative narrative around Black maternal health.”
Discussion
Through in-depth interviews with Black midwifery practice leaders, we explored their perspectives on the key components of Black-led community-centered models of midwifery care and the factors that shape scaling and spread. We found that Black midwifery leaders draw inspiration from the legacy of Black midwives to reimagine perinatal care for Black women and birthing people. This reimagination can be understood not just as clinical innovation but as a Black feminist liberatory practice.32,33 By centering the needs and voices of Black women, challenging the structural oppression that contributes to poor perinatal outcomes, Black midwives are creating healing perinatal spaces that contribute to social and health transformation.
Black midwifery leaders described key components of culturally affirming and community-centered care in Black-led midwifery practices. We found that these components closely aligned with the 21-Point Black Midwives’ Care model and previous research on community-centered models of midwifery care, including the importance of Black racial identity, comprehensive wraparound support, trust, holistic care, and culturally sensitive care.8,9,14,34 Our findings expand published frameworks by highlighting creativity as a key component in shaping these models of care. Black creativity has long functioned as a tool of radical imagination to envision and build new worlds and create new possibilities beyond oppressive systems. 35 The emphasis on creativity that emerged in our interviews likely reflects the unique vantage point of the study participants, who were responsible for not only providing care but designing and sustaining a successful program of care.
Black-led midwifery models stand in opposition to dominant obstetric care models, which are largely shaped by biomedical, hierarchical, and efficiency-driven values and mechanisms. 36 Modern obstetrics is focused on risk management and intervention in a system where care is organized within professional hierarchies that prioritize the authority of the physician and the institution, as emblems of safety and the standard of care.37,38 In contrast, our participants highlighted how Black midwifery care is largely relational and trust-centered, culturally-affirming, and focused on health promotion. The Black midwifery ethic of care extends beyond clinical services to include social, emotional, spiritual and community support, and the programs center community needs, experiences, knowledge and priorities. Consistent with a Black feminist liberatory approach, 32 Black midwifery leaders explicitly acknowledge racism, misogynoir, 39 and structural inequities that shape Black maternal health, and design in response to it, see the power and promise of racial concordance in perinatal care, and leverage innovation, creativity, and adaptability to navigate the structural barriers that exist.
Our interviews highlighted the ways in which the intersection of misogynoir, hostility, and marginalization of midwifery compounds the structural marginalization of Black-led models of midwifery. These two mutually reinforcing dynamics undermined Black midwives’ leadership and legitimacy in the clinical environment. Moreover, they echo attempts by physicians and public health personnel in the 1900s to systematically regulate and eradicate the Black midwife.5,6,40 The persistence of these challenges underscores that reimagining perinatal care to promote health equity will require us to simultaneously confront misogynoir and the systemic devaluation of midwifery.
Scaling Black-led models of care
Today’s Black midwifery leader is deeply attuned to the needs and challenges facing Black women and birthing people and uses clinical expertise and creativity to reimagine care. By building from the traditions of Black midwives, and specifically addressing community needs, these models explicitly confront the systematic marginalization of both Black midwives and Black women and birthing people. If scaled and sustained, these models could reduce disparities in maternal morbidity and mortality, offering a replicable and reimagined model for systems transformation. When asked to consider facilitators and barriers to scaling Black-led models of midwifery care, these leaders articulated a wide range of factors, some of which were relevant to scaling midwifery care in general, while others related to the specific structural challenges that apply to Black-led models of care.
Scaling out
Scaling out Black-led models of care requires us to cultivate pipelines and pathways that increase the number of Black midwives and prepare newly graduated midwives to thrive and grow in their clinical practice. The number of Black midwives has grown in recent years, even outpacing the growth of midwives overall.7,41 The increased awareness regarding Black maternal health inequities and the desire to address inequities has fueled this increase. 42 However, the longevity of these increases remains to be seen. Participants discussed many ongoing challenges referenced in published literature on trends and experiences in the midwifery education and workforce including (1) the experience of anti-Black racism in midwifery education programs, 43 (2) persistent high attrition rates in the first 5 years of practice, 44 (3) burnout among midwives, 44 and (4) forthcoming graduate loan changes that may negatively impact access and affordability of midwifery education. 45
The contributions of this study lie in illuminating the lived experiences of Black midwifery leaders, many of whom described pervasive burnout stemming from the demands of sustaining an innovative and revolutionary practice environment while simultaneously contending to threats to midwifery, and anti-Black racism. Efforts to increase the number of Black midwives must contend with the structural barriers that limit both entry into and retention in the profession. While burnout is often framed as individual physical and mental exhaustion, it actually reflects the deeper structural conditions associated with maternal health care delivery that also drive Black maternal health inequities. 46 Expanding the Black midwifery workforce must be paired with investments and system changes that transform practice and education settings into sustainable environments in which Black women can thrive.
Black-affirming educational and professional development environments like HBCU midwifery programs and Black postgraduate fellowships could help equip midwives for clinical practice settings in which they may experience both marginalization on account of both their race and their profession. These environments are rooted in Black culture, history and achievement, and could provide a supportive community that actively combats the effects of racism by uplifting self-worth, affirming identity, and effecting social impact through collective action. No current HBCU midwifery programs exist, although Morehouse University has started the preaccreditation process, 47 offering hope that a new culturally affirming midwifery educational environment will soon become a reality. Black midwifery fellowships like the CHOICES midwifery fellowship demonstrate the potential of these initiatives to nurture and sustain new graduate midwives. 48 Future studies should examine the effects of culturally affirming educational, training and professional development models on recruitment and retention of Black midwifery students and new midwives.
Scaling up
Reimbursement and policy structures are among the important levers shaping the establishment, survival, and growth of Black-led midwifery models. One major reimbursement lever is pay/reimbursement parity of midwives with physicians across birth settings. While Medicare requires reimbursement of midwives at 100% the fee rate, state-determined Medicaid rates vary. Approximately 30 states and Washington, DC require 100% reimbursement rate, but reimbursement rates in the other 20 states are between 75% and 98%. 49 Reimbursement rates for midwifery services in out-of-hospital settings may widen the disproportionate gaps with birth centers receiving significantly lower facility fees than hospitals (or none at all) and home birth midwives receiving only provider fees, but not fees to cover necessary supplies and equipment. This variation in reimbursement is significant given that Medicaid covers 41% of births. 50 Thus, state policymakers setting reimbursement rates wield substantial power to shape the availability of midwifery care, particularly for individuals with low incomes who receive Medicaid coverage. Furthermore, some payers have other restrictive policy mechanisms including reimbursement restrictions based on whether the midwife has a consulting or collaborative agreement with a physician or reimbursement restrictions based on midwifery credentials, thus excluding Certified Professional Midwives and other direct entry midwives. 51 Similar patterns of inequitable reimbursement for midwifery services are seen for private payers as well, although the trend is particularly pronounced for Medicaid and other public payers such as Tricare and the Children's Health Insurance Program (CHIP). 52 Equitable reimbursement could help to drive policies that promote greater midwifery integration, including independent practice in all care settings, full hospital admitting privileges, greater hospital integration, and broader inclusion of midwives within interdisciplinary care teams across care settings.
Encouragingly, historical precedents suggest that federal payer and reimbursement reform expanded access to and availability of midwives, facilitating midwifery promoting environments in hospitals and ambulatory settings. After the 1980 federal Medicaid mandate required states to cover services provided by CNMs, midwife-attended births rose by 42%. 53 The policy contributed to a wider geographic spread of CNM services, illustrating how financial incentives can expand both the availability of providers and the distribution of care. State and federal policies that mandate equitable reimbursement for midwifery-attended births are critical, especially for midwifery care at birth centers, the only institutional birth setting exclusively led by midwives. Favorable reimbursement could help sustain midwives in independent practice in birth centers and homebirths and influence hospitals to maintain midwifery care. Finally, novel alternative payment models that reward innovation could strengthen Black-led models of care, which advance health equity through new approaches. 54
Scaling deep
Scaling deep is where the foundational work of reimagining perinatal care happens. Reimagining perinatal care is not just about creating new components of care, but rather, it encompasses leaning into new models of thinking and new ways of relating with each other. This requires cultural transformation- shifting narratives toward valuing midwifery and upholding concepts like respect, autonomy, and dignity in care. It also necessitates developing deeply collaborative relationships rooted in solidarity. These actions are critical for creating the conditions that support scaling out and up. In this study, participants especially highlighted the transformative potential of collective action through solidarity with patients, families, and Black-led organizations. The participants also recognized the importance of collaboration with allies including physicians and some predominantly white institutions. The work to advance the vision of Black-led midwifery models of care was one taken up not just by the individuals leading the midwifery practice, but by the wider community committed to the vision. It is through this collective work that we lay the foundation for a reimagined perinatal health system that sustains community-centered models of care.
Limitations and strengths
This study has several limitations and strengths. Although this study included only nine participants, the interviews yielded rich discussions. The perspectives reflect the experiences of Black midwifery leaders, most of whom lived in the South, which may limit transferability to other Black midwives in nonleaderships positions and midwives in other geographic areas. However, the sample was diverse in other ways, including midwives that encompass different educational pathways, levels of education, and clinical care settings. Garnering insights from leaders was a key strength of this study since their active role in creating and sustaining midwifery practices gives them unique insights into the factors that shape scalability.
Conclusion
Black midwives are at the forefront of reimagining care to provide culturally affirming models that center Black racial identity, mutual trust and solidarity, and patient safety. Our study highlights essential components of Black-led community-centered midwifery, as described by the women leading this work. Lessons from their experiences offer critical guidance for scaling and sustaining these models. Our findings underscore key insights for investing in the education, integration, and support of Black midwives. The recommendations offered provide a roadmap for investment and reforms that can strengthen and preserve Black-led community midwifery care.
Authors’ Contributions
N.K.J.: Conceptualization, funding acquisition, investigation, methodology, formal analysis, writing—original draft preparation, writing—review and editing, supervision; S.T.W.: Writing—original draft preparation, investigation, formal analysis, writing—review & editing; Y.T.: Writing—original draft preparation, formal analysis, writing—review and editing.
Supplemental Material
sj-docx-1-heq-10.1177_24731242261462709 — Supplemental material for Perspectives from Black Midwifery Leaders on Scaling Culturally Affirming and Community-Centered Models of Care
Supplemental material, sj-docx-1-heq-10.1177_24731242261462709 for Perspectives from Black Midwifery Leaders on Scaling Culturally Affirming and Community-Centered Models of Care by Noelene K. Jeffers, Sylvie T. Wilson, and Yordanos Tesfai
Footnotes
Acknowledgments
The authors are deeply grateful to the midwives who generously shared their time, perspectives, wisdom and expertise with them. Their openness and commitment to advancing midwifery and to caring for Black women and birthing people made this study possible. We honor their contributions to improving perinatal health care and advancing equity.
Author Disclosure Statement
The authors have no conflicts of interest to declare.
Funding Information
Financial support for the study was provided by discretionary funding provided by the Johns Hopkins School of Nursing. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the article.
Abbreviations
References
Supplementary Material
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