Author: bkellaway

From the moment she learned she was pregnant late last year, TaNefer Camara knew she didn’t want to have her baby in a hospital bed.

Already a mother of three and a part-time lactation consultant at Highland Hospital in Oakland, Camara knew a bit about childbirth. She wanted to deliver at home, surrounded by her family, into the hands of an experienced female birth worker, as her female ancestors once did. And she wanted a Black midwife.

It took the COVID-19 pandemic to get her husband on board. “Up until then, he was like, ‘You’re crazy. We’re going to the hospital,’” she said.

As the COVID-19 pandemic has laid bare health care inequities, more Black women are looking to home birth as a way not only to avoid the coronavirus but also to shun a health system that has contributed to African American women being three to four times more likely to die of childbirth-related causes than white women, regardless of income or education. Researchers argue that the roots of this disparity — one of the widest in women’s health care — lie in long-standing social inequities, from lack of safe housing and healthy food to inferior care provided at the hospitals where Black women tend to give birth.

“It feels like we are needed,” said midwife Kiki Jordan, who co-owns Birthland, a prenatal practice that opened early this year in a 400-square-foot storefront in Oakland’s Temescal neighborhood targeting low-income women of color.

Since the COVID-19 pandemic hit in March, she said, the practice’s clientele has more than tripled.

Images of hospitals inundated with coronavirus patients have sparked a flurry of new interest among women of all races in home births, which account for just over 1% of deliveries in the United States. Birth centers and midwives who attend home births say they’ve been swamped by new clients since the pandemic.

“Every midwife I’m talking to has seen their practice double or sometimes triple in the wake of COVID,” said Jamarah Amani, a Florida midwife and co-founder of the National Black Midwives Alliance.

Many Americans think of giving birth at home as backward and scary, or as a quixotic practice of privileged white women, akin to cloth diaper services and home-cooked baby food.

But the growing interest in home births in recent years has fueled a growing Black midwifery movement that harks back to a venerable, if long-forgotten, tradition in the United States.

Jordan’s practice is now 98% Black, “something I’ve never seen before,” she said. She provides pre- and postnatal care regardless of where women plan to deliver, though the majority of her clientele choose home births.

African American infants are more than twice as likely to die as white infants, and the risks extend across social class. Tennis superstar Serena Williams’ harrowing 2018 account of her own near-death postpartum experience with a blood clot in her lungs and a cascade of life-threatening complications was a sobering reminder that even wealth and fame are no protection from being dismissed or mistreated during one of the most vulnerable moments of a woman’s life.

At least three Black women have died in childbirth since March in New York City, which was hit hard early on by the coronavirus. One of the women, 26-year-old Amber Isaac, had reportedly tried to switch to a home or birth-center delivery after not getting an in-person appointment with her obstetrician as providers abruptly switched to telemedicine in the wake of the shutdown.

For Katrina Ayoola, 29, avoiding unnecessary medical interventions that researchers say can lead to dangerous maternal complications was a key reason for switching to a home birth. As the coronavirus hit last spring, when Ayoola was around five months pregnant with her first baby, she was already frustrated with her obstetricians in Martinez, California. She didn’t like their system of rotating providers, to whom she felt she constantly had to reexplain herself. The last straw was being told to go shopping for a home blood pressure monitor. They were sold out everywhere. “I ended up canceling what would have been an online appointment, and I haven’t heard from them since,” said Ayoola.

“I did not feel cared for,” she said.

On Aug. 1, Ayoola delivered her son, Oluwatayo, at home in Fairfield with her husband, Daré, and her mother at her side following a 29-hour labor supervised by Jordan and her partner, Anjali Sardeshmukh.

“At the hospital, I’d probably have had a C-section,” said Ayoola, who said her home birth was “an amazing, empowering experience,” worth every penny of the out-of-pocket $4,500 the couple paid for it — a discount, based on their insurance and income, from Birthland’s typical $6,500 fee.

Cost is a major barrier for poor people to access out-of-hospital births. Medicaid, the federal-state health insurance program that covers many low-income pregnant women, pays for home births in only a handful of states. Since 2015 these have included California, but reimbursement is low and bureaucratic requirements make it difficult for most midwives to accept Medi-Cal, California’s Medicaid program. A quarter of U.S. states do not even offer midwife licenses, making the practice of home birth effectively illegal.

Jordan led a free-standing birth center in San Rafael that was the first in the state to accept Medi-Cal when it opened in 2016. She and a handful of other Black midwives around the country are leading the effort to make out-of-hospital births more accessible to low-income women, a group that could particularly benefit from community-based midwifery, according to a 2018 study.

Many of these birth workers are struggling to break even, but that’s nothing new.

In past generations, Black midwives sometimes walked miles and stayed days with laboring women, massaging their feet, cooking and babysitting, and reading from the Bible in exchange for a few dollars or a chicken, according to historical accounts. Immigrants and African Americans dominated midwifery during much of this country’s history, and in the South, enslaved women passed from mother to daughter childbirth techniques and remedies brought from West Africa starting in the 1600s.

In certain rural pockets, Black midwives continued to deliver babies for poor Black and white families alike, even into the last century, as modern obstetrics regulated traditional birth attendants virtually out of existence. Midwives delivered half of the nation’s babies in 1900 and just over 10% by the 1930s, as physicians launched a campaign to promote hospital birth as safe and hygienic, while dismissing midwives as “relics of barbarism.”

But in recent years, with hospital birth as the norm, the United States has registered the poorest birth outcomes in the industrialized world. The numbers have worsened during the past 25 years even as they’ve improved in most of the world, largely because of the disproportionate toll on African Americans.

California has led the effort to reverse that trend, cutting its maternal death rate by 55% between 2006 and 2013, though the disparity for Black mothers has persisted.

Researchers have documented countless instances of pregnant African American women being ignored, drug-tested without permission, or sutured without pain medication.

There is a growing consensus among medical researchers and social scientists that discrimination can result in toxic stress that causes maternal complications or premature births. Respectful, holistic prenatal care can improve outcomes, said Jennie Joseph, a British-trained midwife. Her prenatal clinic in Florida serving mostly low-income women of color has had consistently low rates of maternal complications and premature and low-birth-weight babies.

Joseph believes it matters less where a woman gives birth than how she is treated during the previous nine months, and most of her clients deliver in hospitals.

Groups like Amani’s are encouraging more midwives of color to penetrate what she calls the profession’s “old girls’ network.” Just 2% of American midwives are Black, and research has shown that Black patients tend to do better with Black providers.

There is evidence that their numbers are growing with demand, however. California now has about half a dozen licensed Black midwifery practices, including three that have opened in the San Francisco Bay Area since 2017.

Camara said she wanted to support them: She’s had supportive, competent white birth attendants in the past, “but it wasn’t the same,” she said. “This is returning to what we did before.”

At around 6 on a Saturday morning in mid-August, as a heat wave gripped the Bay Area, she phoned Jordan to tell her she was having contractions. Barely two hours later, the midwives helped her give birth to her son, Esangu, 8 pounds, 6 ounces, on her hands and knees on her living room floor.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Participation in clinical trials among Black people is low, according to Food and Drug Administration statistics. Still, including them in coronavirus vaccine trials has been a stated priority for the pharmaceutical companies involved, since African American communities, along with those of Latinos, have suffered disproportionately from the pandemic.

The ongoing trials are moving at a pace that is unprecedented for medical research, with the Trump administration’s vaccine acceleration effort dubbed “Operation Warp Speed.” Yet recruiting minority participants requires sensitivity to a mistrust borne of past and current medical mistreatment. Trust-building cannot be rushed.

So far, participation by minority volunteers in coronavirus trials has increased only slightly compared with typically low levels for other clinical trials — and targeted outreach efforts to recruit more minorities have been slow to launch.

Some of that outreach is taking place at historically black colleges and universities, which are trusted institutions for many Black Americans. At Meharry Medical College in Nashville, Tennessee, researchers have set up in-person meetings with patients they already know. Earlier this month, a half-dozen patients gathered in a cramped conference room on campus. They snacked on turkey sandwiches and potato chips and listened to the pitch from their physician, Dr. Vladimir Berthaud.

“What’s the best hope to get rid of this virus?” he asked them.

“Vaccination,” they replied.

Then Berthaud followed up: “So raise your hand if you would like to take the vaccine?”

Some hands shot up, but not all.

“I ain’t going to be the first one, now,” said Lanette Hayes.

Katrina Thompson said she does eventually want to get a shot for protection against the coronavirus. She explained she’s especially worried about all the residents of her apartment building who don’t seem to be doing the basics of covering their coughs.

“The word ‘vaccination’ don’t scare me,” she said. “The word ‘trial’ do.”

Black Americans have reason to be suspicious — stemming beyond the well-known Tuskegee experiments, in which Black men with syphilis were deceived and mistreated as part of an experiment that went on for decades. Many Black Americans report ongoing mistreatment by medical providers today.

Berthaud is recruiting patients for a clinical trial site he will oversee in Nashville, and he would like more than 300 people of color to enroll. Berthaud, who is Black and from Haiti, appeals to his patients’ sense of duty.

“If you don’t have enough people like you in those vaccine trials, you will not know if it works for you,” he told them. “You will not know.”

For most of the current coronavirus vaccine trials, recruitment mainly takes place online — which often results in mostly white people enrolling.

That’s why Meharry researchers are wooing Black patients with a personal invitation. But they’re not recruiting for the phase 3 trials underway. Meharry’s first trial, for a vaccine candidate by Novavax, doesn’t launch until October.

Other pharmaceutical companies are nearly done recruiting. Moderna said it chose nearly 100 trial sites for their “representative demography.”

The company did not respond to requests for comment but publicizes demographic statistics about the clinical volunteers every week. While somewhat more inclusive than the typical clinical trial, it still is not a good representation of the diversity of the U.S.

For the coronavirus vaccine in particular, the National Institutes of Health has suggested minorities should be overrepresented in testing — perhaps at rates that are double their percentage of the U.S. population.

“We say we want to have everybody included, but really the effort for the vaccinations — in a sense — [is] starting the same way they’ve always been,” said Dr. Dominic Mack, of Morehouse School of Medicine in Atlanta.

He’s working with the NIH to make sure people of color are included in COVID-19 research. Mack said there are no shortcuts if medical research is going to reflect the diversity of the U.S. It takes time to build trust and meaningful relationships with people who have endured a history of abuse or neglect by medical providers, and exclusion from biomedical research and decision-making.

“Now, that being said, the only thing we can do is what we’re doing,” he said — by which he means respectful, unrushed outreach and dialogue.

The primary effort, called the COVID-19 Prevention Network, taps into four existing clinical trial networks designed to advance HIV research. Those networks are based in Seattle, Atlanta, Los Angeles and Durham, North Carolina.

One project will be led by the Rev. Edwin Sanders II of the Metropolitan Interdenominational Church in Nashville. It will involve seven “faith ambassadors” and 30 “clergy consultants” in the African American community working to dispel myths and increase trust in the clinical trial process. But Sanders cautioned this is not about a hard sell. It’s not his job to preach trial participation from the pulpit, he said.

“We are not out beating the drum,” he said, acknowledging that congregants may have legitimate concerns. “I am not going to do anything more than make sure people are able to make an informed choice.”

The danger in lunging for big diversity goals is that it could spark a backlash, meaning minorities might be even less willing to participate, said associate professor Rachel Hardeman, who studies health equity at the University of Minnesota. It’s important that the doctors doing the asking look like the people they’re appealing to, she said.

“It’s racial concordance,” she explained. “It offers this feeling of, ‘You know who I am, you know where I come from, you have my best interests at heart.’”

Historically Black medical institutions in the U.S. are uniquely positioned to do this work. While they haven’t been on the leading edge of recruitment for vaccine trials, they intend to play an important part. The president of Nashville’s Meharry Medical College, Dr. James Hildreth, is an infectious disease researcher. But instead of overseeing the trial site being hosted on his campus, Hildreth has a more modest goal in mind: He plans to participate as a patient, and urge others to join him.

“I think my role is more important in advocating for people to be involved in vaccine studies than to be one of the leaders of the study,” he said.

So at Meharry, Berthaud is the principal investigator. As lunch wraps up in the crowded conference room, he has managed to win over some holdouts.

“Where is the line?” asked Robert Smith. “Where do we sign?”

Smith, with his young grandson in tow, didn’t raise his hand at first when asked if he’d take the vaccine. But after listening to Berthaud, Smith agreed to participate in the clinical trial — for no other reason than the trust he has in Berthaud, his longtime physician.

“He’s not only my doctor; he’s proven that he cares about me,” Smith said.

Persuading hundreds or thousands of Black Americans to sign up will be difficult. But researchers hope their outreach efforts will at least result in more minorities agreeing to take an approved vaccine when available.

This story is part of a partnership that includes Nashville Public Radio, NPR and KHN.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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This story can be republished for free (details).