Black Midwives and Doulas Are Central to Birth Justice

Black women in the United States continue to face maternal mortality rates nearly 3.5 times higher than their white counterparts, according to the latest data from the Centers for Disease Control and Prevention (CDC). While overall U.S. maternal mortality rates have declined since their peak in 2021, Black maternal mortality remains alarmingly high, with 50.3 deaths per 100,000 live births recorded in 2023—one of the highest rates among high-income nations.

The social determinants of health (SDOH)—such as access to care, economic stability, and racial bias in medical settings—continue to shape these disparities. Research shows that more than 80% of pregnancy-related deaths are preventable, yet racial inequities persist due to deeply embedded systemic factors.

Amid these disparities, Black midwives and doulas play an essential role in improving maternal outcomes. Community-centered birth workers, who have long provided holistic, culturally aligned care, are at the forefront of the birth justice movement—a framework that recognizes childbirth as a human rights issue and seeks to address the structural barriers leading to poor maternal health outcomes.

The Black Mamas Matter Alliance (BMMA), a national organization advocating for Black maternal health, convenes experts to discuss these pressing challenges. BMMA emphasizes that those most directly affected by a problem are best positioned to create solutions. The term “Black mamas,” as BMMA defines it, refers to all people of African descent across the diaspora, including those who are transgender or gender-nonconforming.

Birth Justice

Jamarah Amani, executive director of the Southern Birth Justice Network, spoke about birth justice, a movement that seeks to address the root causes of racial disparities in maternal health. “Discourse regarding health equity is ultimately a discourse about bodies,” said Amani, quoting Dr. Camara Jones, a physician, epidemiologist, and former president of the American Public Health Association. “It necessitates analysis of power dynamics that have historically patterned and continue to shape our health experiences, exposures, and opportunities.”

The birth justice movement recognizes that racial disparities in maternal health are not incidental; they are the direct consequence of centuries of systemic neglect, exclusion, and policies that prioritize institutional control over Black reproductive autonomy. Birth justice is not just about addressing disparities—it is about ensuring the fundamental human right to respectful, culturally competent, and safe childbirth experiences, free from discrimination and medical coercion.

The Black maternal mortality crisis is a direct result of structural inequities in health care, including disparities in quality of care, access to preventive services, and medical decision-making. Black birthing individuals often encounter significant barriers to care, particularly when it comes to receiving culturally competent support from medical providers.

“Having conversations about improving health that doesn’t involve how we impact and increase people’s power is an incomplete conversation,” said Amani. She emphasized that health disparities are deeply tied to power disparities—the ways in which systemic structures dictate access, opportunity, and participation in health care. Power, she noted, is not an individual trait but rather something codified in institutional policies and SDOH.

Several key factors contribute to Black maternal health disparities, including:

• Limited access to quality care in both urban and rural areas.
• Higher rates of pregnancy complications, such as preeclampsia and postpartum hemorrhage.
• Implicit bias in medical settings, where Black patients’ concerns are more likely to be dismissed.
• Chronic stress from racism, which has been linked to adverse birth outcomes.

“Structural and institutional racism are preexisting conditions, and we really need to talk about them in this way,” said Amani.

According to the Missouri Department of Health and Senior Services (MDHSS), data from its 2021 Pregnancy-Associated Mortality Review (PAMR) Annual Report indicate that Black women in Missouri face a similarly disproportionate risk. The report found that the pregnancy-related mortality ratio (PRMR) for Black women in Missouri was 72 deaths per 100,000 live births, compared to 26 deaths per 100,000 live births for white women. These findings further illustrate how entrenched disparities—compounded by limited access to care, socioeconomic barriers, and implicit bias—continue to affect Black mothers at the local level, mirroring national trends in maternal health outcomes.

The root causes of Black maternal mortality also include the historical biases embedded in medical education and policy. The child welfare and health care systems still reflect outdated frameworks, including biases embedded in medical education.

The systematic erasure of Black midwives from maternal care was not accidental—it was a deliberate policy decision that privileged physician-led hospital births over community-based, culturally grounded care. These decisions, rooted in racism and economic interests, continue to shape the Black maternal health crisis today.

The birth justice movement calls for policy accountability and structural change in maternal health care. Despite overwhelming data proving that Black-led midwifery and doula care improve maternal and infant health outcomes, restrictive laws in many states continue to make it difficult for Black birth workers to practice. In some states, Medicaid reimbursement for doula services is still not available, leaving many Black families unable to access the culturally competent care they need.

Additionally, medical racism continues to undermine the safety of Black birthing people. Studies confirm that Black patients’ pain is more likely to be dismissed, their symptoms are often ignored, and medical interventions are frequently delayed compared to their white counterparts. These systemic failures are not just medical oversights—they are reproductive injustices that cost lives.

The 1965 Moynihan Report, which framed Black families as inherently dysfunctional due to the absence of traditional nuclear family structures, contributed to policies that pathologized Black motherhood rather than addressing systemic barriers to economic and health care access.

Moynihan’s report was written from a worldview wherein a traditional nuclear family structure was necessary, with men as breadwinners and women tending to the home. Though many people lauded the report and its author as a champion of hard truths, the report is often cited but rarely read in full, and the realities of its message—and the policies built upon it—ultimately condemned Black families rather than supporting them.

“As we continue to have these conversations, we must shift our focus from blaming Black mothers to dismantling the systemic barriers that have historically denied them equitable care,” said Amani.

Black lives—and Black maternal health—must be valued beyond economic productivity.

The Role of Midwifery Care

Increasingly, birthing people are seeking out-of-hospital births, driven by concerns about separation from their babies or doulas, increased surgical births, fears of their rights being denied, financial and family stresses, lack of transportation and easy access, insurance coverage, and exposure to viruses.

“There has been a shift in midwifery over the last few decades from being a community-based tool and health care right to being more seen as a boutique service for wealthy, educated, predominantly white families,” said Amani. “Part of the work of building a birth justice movement is to shift the movement back to centering Black families. Home births are for Black families.”

Historically, Black midwives have played a central role in maternal and infant care, but as policy and legislation changed, their ability to continue that work was heavily diminished. In 1900, midwives attended about 50% of births, but by 1935 that number had dropped to 10%. 

Grand midwives—who traditionally served as healers, birth attendants, and abortion providers—were systematically removed from practice as medical institutions pushed for hospital births and physician-led care. These policies left many Black communities without access to midwifery, prenatal care, or abortion services, disproportionately impacting maternal health outcomes.

“One of the darkest moments of American history,” said Shafia Monroe, founder of the International Center for Traditional Childbearing, now the National Association to Advance Black Birth (NAABB) “was the systematic eradication of the African American midwife from her community, resulting in a legacy of birth injustices.”

For some, the lack of compassionate hospital care led them to seek alternative birth settings. Brittany “Tru” Kellman, founder of Jamaa Birth Village, shared how her traumatic hospital experiences shaped her advocacy for Black-led midwifery care.  

“Ultimately, I went on to have my first two children about five years apart. Each one of those births was at two different local hospitals, but very, very traumatizing, and I was harmed in different ways,” Kellman said. “So with a passion to see past that trauma and to really reach the vision that was bestowed upon me to see a compassionate midwifery care center for Black people, I persevered. I ended up having my third son at home. I had a very successful holistic midwife-led home birth.”

The vast majority of birthing people are not having high-risk pregnancies or births but still seek care in a hospital because that is what is expected. According to the CDC, 92%–94% of all pregnancies are considered low-risk, but 98% of births occur in the hospital. Kellman highlighted the trend as an improper risk-appropriate care mechanism, likening the practice to scheduling regular dental checkups with oral surgeons rather than oral hygienists. Over 90% of hospital births are delivered by physicians, and only 8.7% are delivered by certified nurse-midwives or certified midwives.  This pattern is mirrored in Missouri. Data from the U.S. Government Accountability Office shows that nearly all births in the state take place in hospital settings, while about 7% are attended by a midwife. This reliance on physician-led care, even for low-risk pregnancies, suggests that the current care model may not be ideally aligned with the needs of most birthing people. 

With Black mamas dying at 3.5 times the rate of white women, according to Child Stats, and the root causes of Black maternal mortality resting firmly in the racist roots of the medical system, the need for Black midwifery is urgent—but only 6%–7% of midwives in the U.S. identify as Black, highlighting a critical gap in culturally competent care. In light of such great need, Kellman said, “It is up to Black midwives and birth workers to implement holistic wraparound care services to address core maternal health issues.” 

Spreading the word is the first step on the path to repairing the Black maternal health gap. Altruism, Inc., a 501(c)(3) nonprofit, founded The Maternal and Infant Health (MaIH) Center in 2022 to directly address disparities in prenatal and postpartum care. Located in Lexington, Missouri, The MaIH Center provides critical maternal health support, including doula services, midwifery referrals, and maternal health education, with a focus on rural families.

Despite its impact, significant barriers remain—especially in rural maternal health care. Limited provider availability, transportation challenges, and gaps in funding continue to make it difficult for expectant and postpartum parents to receive consistent, culturally competent care. Expanding access to Black-led midwifery and doula services remains a key goal of birth justice advocates working to remove legislative and financial obstacles that prevent families from receiving the care they need.

But ensuring birth justice requires more than just awareness—it requires action. Policy changes, community-led initiatives, and increased investment in Black maternal health programs are critical to eliminating these disparities. 

Advocacy efforts must focus on:

• Expanding state and federal funding for Black-led midwifery training programs and birth centers.
• Removing legislative barriers that restrict midwives and doulas from practicing.
• Mandating Medicaid reimbursement for doula and midwifery services in all states.
• Holding hospitals and providers accountable for racial disparities in maternal care.
• Shifting power back to communities by supporting grassroots maternal health initiatives.

What can you do?

• Contact your state and federal representatives to demand expanded midwifery access and Medicaid reimbursement for doula care.
• Support Black-led maternal health organizations by donating, volunteering, or amplifying their work. To learn more about The MaIH Center’s work, visit TheMaIHCenter.org.
• Advocate for hospital accountability by pushing for transparency in maternal health outcomes and provider bias training.
• Educate your community about birth justice and the impact of systemic racism in maternal care.

Birth justice is not optional—it is a human right. The U.S. must confront the deeply embedded racism in maternal care and push for systemic change. The time for incremental progress is over. The moment for real action is now.