A black midwives’ conference next week follows an AMA salvo against home-birth attendants. A conference organizer says black women need more of the holistic care midwives provide, not less. Third in a series on black maternal health.

Shafia Monroe

0NEW YORK (WOMENSENEWS)–Shafia Monroe’s sixth annual International Black Midwives and Healers Conference, taking place in New York’s Harlem neighborhood Oct. 10-12, comes in the middle of a showdown between home-birth midwives and the American Medical Association.

In June the Chicago-based physicians’ group, the country’s largest, promised to back state legislation that restricts licensing to nurse midwives, those who have additional nursing training and certification required to work in hospitals.

The group wants to bar licensing to certified professional midwives. These midwives assist home births and specialize in the intimate, emotional and family-focused care of mothers. They often promote vaginal births over Caesarean sections, which precede the majority of maternal deaths in the United States.

Certified professional midwives are a critical component to meet the growing maternal health needs in the black community," said Monroe, noting that every sort of midwife is needed to reduce maternal morality rates among African American women.

There are two major types of midwife license categories. A certified nurse midwife is a registered nurse trained for hospital care. A certified professional midwife specializes in out-of-hospital births, in homes and birthing centers.

African American women’s rates for dying during pregnancy, labor and immediately after giving birth are more than triple the national rate of maternal mortality. Roughly 31.7 black maternal deaths occur per 100,000 live births in comparison to 12.4 maternal death per all 100,000 births in the United States, according to the Centers for Disease Control and Prevention.

Monroe expects her conference, "Renaissance, Resistance, Revolution, Reclaiming the Wise Women Within," to draw about 300 birth activists for a chance to talk shop about topics ranging from herbal medicine to leadership to wellness. Founder of the International Center for Traditional Childbearing in Portland, Ore., Monroe is also planning a street rally to promote the cause of mothers against obstetric interventions such as Caesarean sections.

When Monroe gained her license 25 years ago, the certified professional midwife category now drawing AMA censure didn’t exist in Massachusetts where she lived, she said. So she went for a third type–certified midwife–which is now fairly rare and is conveyed to midwives who can work in hospitals but have less training than nurse midwives.

Top Legislative Priority

In taking its position against home births, the AMA teamed with the Washington-based American College of Obstetricians and Gynecologists, which made stripping the licenses of certified professional midwives and ending the acceptance of home births its top legislative lobbying priority in 2008.

Dr. Erin Tracy, a physician at Massachusetts General Hospital in Boston and an American College of Obstetricians delegate to the American Medical Association, underscores her two organizations’ support for nurse midwives, who have passed tests by the American College of Nurse Midwives. The vast majority of these health care providers–96 percent–work in hospitals.

Certified professional midwives, by contrast, are not required to hold a high school degree, she notes, and only need to have conducted 20 deliveries to get a license. "Interns in hospitals see that volume in their first month," she told Women’s eNews in a recent interview.

Activists say the crackdowns on out-of-hospital midwives come at an odd moment given that black maternal deaths are contributing to the United States’ 41st place ranking among all nations in a 2007 maternal mortality report by the World Health Organization.

"How bad does it have to get in the United States maternity care system, in terms of the number of C-sections, maternal deaths and the racial disparities in birth outcomes?" asked Steff Hedenkamp, a coordinator with the Washington-based Big Push for Midwives Campaign, in a phone interview. "How bad does it have to get to stop fighting the midwives’ model of care versus embracing it?"

Pushing for Regulation and Licensing

Big Push for Midwives’ activists in 24 states, the District of Columbia, Puerto Rico and Canada are seeking regulation and licensing for certified professional midwives who work in homes and may help women who are losing the services of local doctors. Activists are meeting with legislators to craft bills to help fill local resource gaps.

A week after the AMA passed its new resolution, midwife activists, including the Big Push and Friends of Missouri Midwives, won a Missouri Supreme Court case that approved the licensing of certified professional midwives.

Big Push also has a range of federal policy initiatives such as making certified professional midwives’ at-home services eligible for reimbursement under government health insurance programs for low-income people.

Big Push activists are also trying to stem the rapid pace of closures of midwife training programs around the country. Three programs have closed in the South in the past five years, including in Miami, where rates for C-sections top the nation, comprising 42 percent of all births in the city.

Home-based midwife activists say the success of nurse midwives in hospitals proves the potential for midwifery to correct some of the maternal health problems concentrated in the black community. A principle part of their argument is that while physician-patient relations are more "episodic," nurse midwives spend a greater deal developing emotional bonds with mothers.

Going Beyond the Clinic

As a proponent of that view, Monroe says it’s important to look beyond strict clinical boundaries for the causes of black women’s worse maternal maladies.

Not only do women of color have barriers to enter the health care system, but also they often don’t see health care providers that reflect their cultural lifestyle, Monroe said.

Living with racial bias raises stress levels and fuels hypertension, placing pregnant black women, despite their income and education levels, at a greater risk for complications, Monroe added.

Monroe cites a 1998 Centers for Disease Control and Prevention study that compared vaginal, low-risk births delivered by nurse midwives and physicians to demonstrate the importance of midwives. Despite attending higher risk populations such as African Americans, American Indians and teens, nurse midwives had a 19 percent lower risk of infant death than physicians.

"Certified nurse midwives provide a safe and viable alternative to maternity care in the United States," lead researcher Marian F. MacDorman wrote.

"We must re-establish black midwives to serve as social change agents," Monroe said, noting that black midwives historically offered a range of services from marriage counseling and foster care to political organizing, filling in where mainstream society denied black women equal care and access to health services.

Maternal deaths in the United States have steadily increased since the 1970s–along with a rise in Caesarean sections–while growing numbers of physicians specializing in reproductive health care, obstetricians and gynecologists, are closing their practices due to the rapidly rising cost of malpractice insurance.

In 2004, researchers with the American College of Obstetricians and Gynecologists surveyed its members and found 1 in 7 giving up their practice because of the risk of liability claims. More than 75 percent of the group’s members said they had been sued at least once.

"Women," Monroe said, "are having to drive long ways to have a baby, some having babies on the side of the road."

Malena Amusa is a New York City-based journalist. She will spend the rest of 2008 in Delhi, India, reporting business news.

This series is supported by the W.K. Kellogg Foundation.

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