A Better Birth Is Possible

Written by
Ruha Benjamin
Sept. 27, 2022

As a young Black woman, I saw my pregnancy treated like a problem. So I ditched the doctors for home delivery and found an alternative model for health care.

SEPTEMBER 2000, ATLANTA. I had just celebrated my 23rd birthday. After a summer spent cashiering at Whole Foods for $8.25 an hour, and with my senior year at Spelman College about to start, I was already stress-planning my schedule. For a moment, though, all that worry came to a pause. I stood in my cramped apartment bathroom, heart racing, and called Shawn in to join me. Together we stared at the pregnancy test strip. Though deep down I already knew the result—my cycle ran like clockwork—I still held my breath until the second pink line appeared.

When I entered the campus gates that fall semester, I carried more than a baby. Hitched to me was also the burden of a degrading narrative about what it meant to be young, pregnant, and Black. At the time, the inflamed rhetoric of “babies having babies” was heavy in the air, and though I wasn’t a teenager, I was much younger than most college-educated women who decide to become mothers. According to the stereotypes, I was lazy, promiscuous, and irresponsible—an image that Spelman, an institution known as a bastion of Black middle-class respectability, had been trying for over a century to distance itself from.

The previous year, while digging through archives for a junior term paper, I had come across a 1989 Time interview with Toni Morrison in which she was asked whether the “crisis” of teenage pregnancy was shutting down opportunity for young women: “You don’t feel these girls will never know whether they could have been teachers?” Morrison replied:

They can be teachers. They can be brain surgeons. We have to help them become brain surgeons. That’s my job. I want to take them all in my arms and say, Your baby is beautiful and so are you and, honey, you can do it. And when you do, call me—I will take care of your baby. That’s the attitude you have to have about human life … I don’t think anybody cares about unwed mothers unless they’re Black—or poor. The question is not morality, the question is money. That’s what we’re upset about.

Almost a decade after the interview, sociologist Kristin Luker published Dubious Conceptions: The Politics of Teenage Pregnancy, offering a powerful refutation of what politicians and pundits called the “epidemic of early childbearing.” Luker demonstrated that, contrary to the racist depictions of teenage mothers as Black girls, most were actually white and, at 18 and 19 years old, were legal adults. Luker’s data also suggested that early childbearing was an indicator of poverty and social ills rather than a cause, and that postponing childbearing did not magically change those conditions. So, instead of stigmatizing and punishing young people for having children before they are economically independent, Americans should demand programs that expand education and job opportunities for impoverished youth. (Later, in graduate school at the University of California, Berkeley, I would become a student of Luker’s—digesting the data after already having lived the story.)

The real “crisis” of Black pregnancy is not youth or poverty or unpreparedness; it’s death.

As a pregnant undergraduate, I didn’t have Luker’s statistics at hand. But I knew intuitively that reproduction by those who are white, wealthy, and able-bodied is smiled upon by many people who adhere to a eugenically stained view of the world—policy makers and pundits, medical professionals, and religious zealots among them—while babies of color, those born to poor families, and those with disabilities are often seen as burdens. Eventually, I would learn that cultural anxieties about “excess fertility” among nonwhite populations and about the declining birth rate of white populations are two sides of the same coin. No amount of moralizing about “babies having babies” could hide the underlying disdain directed toward those who didn’t come from “superior stock.”

The first time I stopped by the student health clinic to ask whether my health insurance plan covered pregnancy-related care, a Black woman behind the desk noted with slight irritation, barely looking at me, that, yes, it was covered, “like any other illness.” Pregnancy, but especially Black pregnancy, was a disorder that required medical intervention. I realized that even at an institution created for Black women, I couldn’t expect care, concern, or congratulations. And although the receptionist’s words still ring in my ears, what’s far more worrisome are the disastrous effects when those in power pathologize Black reproduction.

THE REAL “CRISIS” of Black pregnancy is not youth or poverty or unpreparedness; it’s death. Black women in the United States are three to four times more likely to die during pregnancy and childbirth than white women. This rate does not vary by income or education. Black college-educated women have a higher infant mortality rate than white women who never graduate high school. Black women are also 2.5 times more likely to deliver their babies preterm than white women.

Some observers attribute the higher rate of maternal mortality and preterm birth among Black women to higher rates of obesity, diabetes, and other risk factors. But as Elliot Main, a clinical professor of obstetrics and gynecology at Stanford, says, the focus should turn to the treatment of Black women by hospital staff: “Are they listened to? Are they included as part of the team?” Too often, medical professionals discount the concerns of Black women, downplay their needs, and regard them as unfit mothers. Hospital staff callously interrogate their sexual histories and send them home with symptoms that turn out to be serious. The experience for Black LGBTQIA+ patients and people with disabilities can be even more alienating and hazardous. Taken together, this is what medical anthropologist Dána-Ain Davis terms “obstetric racism.”

In the PBS documentary Unnatural Causes, neonatologist Richard David put it this way: “There’s something about growing up as a Black female in the United States that is not good for your childbearing health. I don’t know how else to summarize it.” Even this, though, misattributes the source of harm; the problem is not growing up Black and female, but growing up in a racist and sexist society. Racism, not race, is the risk factor.

Furthermore, the American medical industry incentivizes high-tech interventions and prioritizes convenience for doctors. Cesarean sections provide a stark example. The procedure can be lifesaving, but it is invasive, high-risk, and increases rates of blood clots, infection, hemorrhage, and other adverse outcomes for birthing people. Planned C-sections typically lead to fewer adverse outcomes than emergency procedures but have all the risks of major surgery. The appeal of C-sections, for hospitals, is that they are efficient—the operation takes about 45 minutes to perform, whereas a vaginal birth typically takes hours or even days. A 2013 study of 72 hospitals across 16 states found that more C-sections are performed on weekdays during doctors’ meal times and shift changes. Health insurance, too, pays out more money for cesareans than it does for vaginal births. Researchers in Minnesota found that when the financial incentives were removed in the state’s Medicaid program in 2009, the number of C-sections went down. Finally, one of the biggest drivers of high C-section rates is malpractice lawsuits; according to physician surveys, obstetricians see performing C-sections as putting them at less risk for litigation.

The US has one of the highest rates of C-sections in the world—almost double the rate of France, Sweden, and Finland, countries with publicly funded health care systems. And Black patients in the US have the highest rate of C-sections. If you are Black and in labor near the time of a shift change in a state with high malpractice premiums—watch out.

WHEN I RETURNED to school after the winter holidays, I was in my second trimester, and my belly was just becoming visible. I spent part of the break thrifting for loose clothes I could repurpose as maternity wear. When one of my Spelman sisters who moonlighted as a seamstress offered to make me some custom dresses, I searched up and down the aisles of a fabric store on the outskirts of the city until I found three perfect prints. On the first day of spring classes I rocked one of my new dresses with room for a growing baby bump.

But the weight of a growing baby and the cultural baggage of Black pathology was getting heavier. Rather than offer a smile, passersby around town and on campus often shot me looks that combined pity and disparagement, as if they were encountering a contagion. When I rode the crowded 2 bus and transferred to the train from North Avenue Station to campus, I was rarely offered a seat. I needed to lighten my load.

I reached out to my friend Abena, who had recently delivered her daughter with a local Black midwife. Unlike the frenzied episodes of A Baby Story I was binge-watching on TLC at the time, Abena described the calmness and encouragement she had experienced before, during, and after labor. I’d been imagining a scenario where I would be confined to a room, plugged into monitors, and surrounded by hospital staff I’d never met, so what appealed to me most while listening to Abena was the promise of developing a trusting relationship over many months with the person who would attend my birth.

Abena introduced me to Sarahn Henderson, or “Mama Sarahn,” as she was affectionately known. Sarahn had been catching babies across metro Atlanta for over two decades, even delivering one of my college classmates. (By now she has assisted in more than 1,000 births.) She was welcoming to us broke students, charging a lowered fee of $1,200 that was payable in monthly installments. By comparison, the average cost for hospital births in the US is more than $10,000, and it can rise to as much as $30,000.

Why do we assume that a medicalized approach is the best way to care for people through pregnancy and childbirth?

When Shawn and I first met with Sarahn, I immediately noticed her waist-length locs. In my memory, she couldn’t have been more than 5 feet tall, and the two long plaits that flowed over her shoulders gave her a playful and easygoing aura. At her ranch-style home, we sat on pillows on the floor, the comforting smell of essential oils and incense in the air. That meeting was mostly about us. What are you excited for? What are you nervous about? Sarahn seemed to turn each word over at least once, making sure it was carefully, gently delivered.

My experience with Sarahn included monthly, then biweekly and weekly, prenatal visits, as well as labor support and two to three postnatal visits. The quality of care and education that Shawn and I received was priceless. But uncertified midwifery is effectively illegal in Georgia, because the state administers licenses only to those with nursing degrees. Births attended by unlicensed “direct entry” midwives are not covered by Medicaid.

Soon after that first meeting with Sarahn, I chose to write a comparative study of midwifery and obstetrics for my senior honor’s sociology thesis. Then, like now, I was curious about how different schools of thought and industries create conditions that come to be seen as natural, normal, and commonsense. Why do we assume that a medicalized approach is the best way to care for people through pregnancy and childbirth? How did the once common practice of Black midwifery in Georgia get run underground?

For a group project in my medical anthropology class, my classmates and I performed a birthing scene on the professor’s large wooden desk. It was a frenzied spectacle involving a patient—who else but me—huffing and puffing in the throes of childbirth. A nurse and a doctor continuously checked various devices, while the patient, confined to her bed, was never directly consulted. The nurse and doctor, nearing the end of their shifts, looked impatiently at the clock on the wall, noting that the patient was taking too long, before finally rushing her into surgery. End scene.

In contrast, we then presented a midwife’s unhurried technique. The laboring woman moved freely around the room, deciding what positions felt best, while the midwife suggested ways to ease the pain. Afterward, our group led a discussion about childbirth literature. One of the books was a beautifully illustrated tome depicting how people give birth worldwide. It was one of many texts that made me feel less strange and afraid, as I observed women around my age pushing out babies without high-tech monitoring or medical interventions.

In my research, one of my go-to prenatal books was Birthing from Within, by home-birth midwife Pam England and psychologist Rob Horowitz. There I read that in the 1920s, the vast majority of Americans gave birth at home, and that the percentage of hospital births remained low through the mid-1940s. According to a more recent report by the Institute of Medicine, in 1900 nearly all US births happened at home, but 40 years later more than half took place in a hospital. By 1969, the percentage of hospital births rose to 99 percent. What happened?

In November 1921, US Congress passed the Sheppard-Towner Maternity and Infancy Protection Act, which medicalized pregnancy and childbirth. Maternal health and childcare came under government control, and midwives suddenly needed training and licenses. The effect of this was to restrict access and privilege nurse-midwives. In the following decades, the American Medical Association and the American College of Obstetricians and Gynecologists began a campaign to discredit community-based midwives and home births in an effort to increase their own legitimacy and earning power.

The majority of midwives were Black, so it was easy for doctors to spread suspicions that they were untrained or incompetent and that they used witchcraft and sorcery, while casting white, male doctors as the safer bet. Later, certified nurse-midwives, the vast majority of them white, would join the effort to discredit and exclude Black midwives from their ranks. In this effort, reads a Drexel University College of Nursing and Health Professions study, many doctors “ignored the reality that traditional immigrant and African American midwives had better maternal outcomes than the general practitioners delivering babies at that time.” Black midwives, most of whom could not afford permits and formal classes, cared for rural and impoverished people while white physicians and licensed midwives increasingly cared for those who could afford their services. The gatekeeping effect lasted; during my pregnancy, practitioners of the “natural childbirth movement” were mostly wealthy white women.

THE WISDOM OF Black communities already knows how to keep Black parents and babies alive and well. Research confirms that while midwifery and doula support improve maternal and infant health across the board, it has the greatest effects for the socially disadvantaged. Births assisted by midwives and doulas in hospitals have fewer complications, lower C-section rates, lower rates of preterm birth, fewer low-birthweight infants and neonatal deaths, higher rates of breastfeeding, and less postpartum depression and anxiety.

The doula effect is a model for all of health care, showing us what it looks like to accompany people when they are at their most vulnerable.

A 2013 study looked at more than 200 expectant mothers in Greensboro, North Carolina, the majority of them low-income and living in high-poverty neighborhoods. About half of the births were doula-assisted. The study found that the other half of the births, without doulas, were twice as likely to present complications for the mother or baby, and those mothers were four times as likely to deliver a low-birthweight baby. In a comprehensive review of 27 clinical trials involving nearly 16,000 women across 17 countries, people who had continuous support during childbirth experienced shorter labors and fewer C-sections, were less likely to report negative feelings about childbirth, and were less likely to develop depressive symptoms.

One theory accounting for these health differences is called the harsh environment theory. Modern childbirth has been medicalized and moved outside the home, exposing mothers to the multitude of stressors that come along with the discomforts of a hospital room and medical staff who don’t know you. Contrast this with the doula effect: Even in a hospital, the presence of another person to act in support can buffer this harsh environment, and people who give birth accompanied by a doula report less pain. Frequent eye contact and a soothing touch can suppress stress hormones and create a spike in oxytocin and endorphins. The doula effect, in this way, is a model for all of health care, showing us what it looks like to accompany people when they are at their most vulnerable.

Importantly, the services of midwives and doulas are not enough on their own—they must be integrated into the health care system in a culturally sustaining way. In the United States, at-home births are associated with twice the rate of infant death and three times the rate of neonatal seizures. In countries such as Canada, where health care covers home births and birthing centers with midwife assistance, there is no increased risk.

The American health care system’s resistance to doulas and midwives began to give way during the Covid-19 pandemic. As being in a hospital became increasingly risky for everyone, the number of people seeking home births surged. To meet demand, New York state began trying to quickly authorize birthing centers as alternatives to hospitals. Now, too, with the overturning of Roe v. Wade, the vital work of abortion doulas, such as through the Bay Area Doula Project, is gaining attention. (Full-spectrum doulas support people through childbirth, abortion, miscarriage, infertility, and menopause.)

In this critical moment, we must hold on to legal scholar Dorothy Roberts’ reframing of “reproductive rights” as going beyond individual freedom: Yes, the right to abortion is critical, but so is a more socially expansive vision of reproductive justice, what Atlanta-based organization SisterSong envisions as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”

Sarahn and other Black midwives across Georgia are pushing for legislation to certify midwifery practitioners who learn their craft through a community-based apprenticeship model, so that they no longer have to practice outside the law. On the federal level, a “Momnibus” Act proposed by the Black Maternal Health Caucus was passed last year in the House of Representatives with the goal of closing the racial gap in maternal and infant mortality, though parts of the act are still stalled. Among other measures, the act would increase funding for training community-based birth workers, doulas, and midwives. California also signed its own version of the act into law.

Together, maternal and infant health provide the most sensitive indicators of the overall health of any society. With these kinds of risks in mind, many midwives provide wraparound social support, or “gap management,” as Jennie Joseph, a Black midwife in Florida, calls it. This is when a team of birth workers extends support beyond the birth itself to include mental-health services, food and housing security, and help with a person’s immigration status. It’s an approach that centers the whole person. It prioritizes autonomy, trust, and collaboration. It is a model for our entire health care system. But fixing the system should not be placed entirely on the shoulders of midwives.

IN EARLY MAY 2001, after putting the finishing touches on my thesis, I stopped by Kinko’s to have the manuscript bound. As I reached over the counter to hand the stack of pages to the cashier, I felt a light needling across my lower back. The cashier told me the manuscript would be ready in 24 hours, and I explained that I didn’t have that long. I needed it bound ASAP. I was in labor.

Two long days later, with Sarahn, her apprentice, my mother, and Shawn circling around one another in our cozy apartment off of Ponce de Leon Avenue, I pushed out an obdurate 7.5-pound creature with a cone-shaped head. It was a week before my college graduation.

When my contractions first started, I had sent a copy of my valedictory speech to one of my professors because I had no idea whether I’d want to be out in the world so soon after becoming a milk dispenser. It turned out that with Mama Sarahn’s expert aftercare—especially her soothing sitz baths—I felt energetic, alert, and ready to move about almost immediately.

Delivering a child on my terms reinforced an already stubborn orientation I had against convention. Although I learned a lot in the library stacks about how medicine sought to discipline birthing bodies, I didn’t realize what that entailed until my own body was contracting, leaking, tearing, and howling. Knowledge about childbirth is undisciplined. It is embodied, experiential, and felt. “Sometimes a scream is better than a thesis,” as Ralph Waldo Emerson put it. Yet medically managed reproduction sedates these screams. Perhaps that is the point. If submitting to a cascade of medical interventions prepares us to become docile patients, then maybe an empowering birth experience can embolden people. I certainly felt a new-mom swagger—not only did I squeeze out a stubborn babe, but I also delivered myself.

Of course, I didn’t do it alone. In addition to Mama Sarahn and her apprentice’s expert care, my mom and Shawn cooked and cleaned, rocked and burped a colicky newborn, changed diapers and washed clothes, and let me sleep and nurse intermittently.

A week after giving birth, I stood on the stage in Sisters Chapel at Spelman. There, with leaky breasts, I was able to deliver the graduation address to the class of 2001—not because I was exceptional, but because I was surrounded by people who had taken Toni Morrison’s gospel to heart: “Your baby is beautiful and so are you and, honey, you can do it. And when you do, call me—I will take care of your baby.”

This article is adapted from Viral Justice: How We Grow the World We Want, by Ruha Benjamin. The book will be published next month by Princeton University Press.

Artwork courtesy of the artist and Assembly.

This story has been updated to clarify that the outcomes of births assisted by midwives and doulas referenced were studied in hospital settings, and to add information about risks associated with home births in the US.