In Arizona, Birth Workers Of Color Fight For More Access

It's been almost 15 years, but for Lakisa Muhammad, it's still hard to look back on all that went wrong with her daughter's delivery.

She expected a fulfilling experience — an all-natural water birth with a midwife by her side. But in the weeks before her due date, the birth center where she had scheduled the delivery suddenly closed its doors. It was time for a new plan.

Her first children — twins born in 2003 — had been delivered at a hospital that provided a free doula, Lamaze classes, a lactation consultant and a battery of tests to ensure the babies' health. The experience was so good, she decided to give it another try.

On the day of her daughter's birth, Muhammad arrived at the hospital in Arizona and was told she needed an emergency cesarean section. That's when the problems began.

She remembers the fluorescent lights glaring into her eyes as she found herself propped up against the cold operation table. Confusion and panic set in. Doctors poked and prodded her for what felt like hours. She recalls nothing more painful or unsettling in her life.

After what seemed like a tumultuous delivery, Muhammad gave birth to a girl she lovingly referred to as her "little nugget." But then, hours passed and no one checked up on her, she said. Lying on the bed, Muhammad felt uneasy.

"I remember I stood up, planted my feet on the side of the bed. Stood up straight, and blood just dripped down to the floor," she said.

She was still shaken from the surgery and too afraid to call for a nurse.

She felt invisible, mistreated. The entire process was all so "cold," she said. "Traumatic."

For a while, she tried to rationalize why things happened the way they did. "I really thought that maybe it was because, well, I am just showing up at the door and they don't know if I was pregnant this whole time and maybe haven't gotten care," she said.

But then she heard similar stories from other Black women and wondered: Could it be because of the color of their skin?

"At that time, I didn't relate it to the fact that I was Black," Muhammad said.

She didn't want anyone else to go through the same experience. She remembered how much easier it had been with a doula by her side.

"That's the way my journey in the birth world began," she said.

"Soldiers on the battlefield"

Muhammad soon ushered herself into a career as a doula, and then a midwifery program. Today, she's a proud mother of three and works to offer care to Black women across Arizona. Muhammad said Black birth workers like herself are "essentially soldiers on the battlefield" in a line of work that is more than 90% white.

Both doulas and midwives offer prenatal support, but their roles are somewhat different. Certified nurse-midwives have years of medical training and schooling, are required to pass a nurse-midwife examination and seek state licensure before they can work with patients. They not only offer care throughout a pregnancy and postpartum, but can also deliver babies.

Doulas focus more on providing emotional and physical support both before, during and after the birth process. While doulas often undergo training and receive certifications, neither is required to become one as there is currently no federal regulation of the profession.

Muhammad and other birth workers of color believe that having more of them in the field could help reverse some of the sobering statistics facing millions of new mothers across the country. Black women, for example, are more than three times more likely to die from pregnancy than white women, according to data from the Centers for Disease Control and Prevention. Their babies are also more likely to die before their first birthday — a rate of 10.8 deaths per 1,000 childbirths, compared to 4.6 deaths per 1,000 births for white children.

Research has shown that a health care worker's race may play a role in reducing mortality rates, especially for communities of color. For example, a 2020 study published in the journal PNAS found that when Black newborns are cared for by Black doctors, their mortality rates, relative to white newborns, are cut roughly in half.

But growing the ranks of birth workers who are Black or Brown is just part of the challenge for which advocates like Muhammad are trying to find a solution. Another is the issue of access.

In Arizona, as in nearly every state across the country, it can be particularly difficult for communities of color to access prenatal care. While certified nurse-midwives can be reimbursed through the state's Medicaid program, doulas are not, meaning it is usually affluent and predominantly white women who benefit from them, according to Will Humble, executive director of the Arizona Public Health Association. This has left women of color shut out from practically all of the benefits of having a doula, according to Humble, such as fewer cesarean sections and preterm births, higher rates of breastfeeding and even births that cost less.

It's an issue that has started to gain attention in Washington. In February, members of the Black Maternal Health Caucus in Congress introduced legislation designed to erase racial and ethnic disparities in maternal health outcomes. The "Momnibus," as the package is being called, includes $50 million in funding for birth workers across the country. It also requires study into what one of the legislation's authors, Rep. Alma Adams (D-N.C.), calls "the barriers that prevent individuals — especially women of color — from entering maternity care professions."

"Countless local organizations and perinatal workers are working tirelessly already to improve outcomes for Black Americans and communities of color," Adams said in a statement to NPR. "The Momnibus would bolster and expand those efforts and help to save lives."

A debate in Arizona

In Arizona, a similar effort to expand access to prenatal care has been slowly moving through the state legislature. If passed, the measure would move Arizona one step closer to becoming the third state in the nation — after Minnesota and Oregon — to allow the services of doulas to be reimbursed under Medicaid. It would do so by establishing certification standards for doulas, similar to those already in place for midwives.

The bill was introduced by state Sen. Kelly Townsend, a doula herself and staunch Republican who represents the mostly white east side of the city of Mesa.

The bill's supporters say the measure would take doula services from being something that is predominantly utilized by white upper middle-income women, and make them more accessible to communities of color. But the legislation has run up against unexpected opposition from a number of groups representing birth workers, who say it would do more harm than good.

At the center of the dispute is the bill's proposed accreditation standards. The bill calls for a bevy of requirements that doulas would need to meet in order to win certification from the state, including proof of at least 30 hours of instruction. Doulas would also need to pay recurring fees in order to maintain their certification with the state.

Critics say that ingrained within the bill is an inherent bias against doulas who have been trained in ancestral or non-Western practices — a group largely made up of Black or Brown birth workers, as well as those from Native communities.

"That doesn't mean we don't believe there should be some type of accreditation," said Maria Parra Cano, executive director of the group Cihuapactli Collective, a Phoenix-based advocacy group for Indigenous families and birth workers. "We believe that if you have 20 years of learning from a traditional healer or traditional birth worker, or having the lineage and information shared with you ... you should be able to provide a service to somebody."

Townsend has pushed back on the criticism. Under the text of the bill, those who don't meet the standards can still acquire state certification, but only if they have been practicing for at least five years and belong to a nationally recognized doula organization. And if there are doulas who don't want state certification, she says, nothing requires them to get it.

"The nice thing about the bill is that it does not require that a doula become certified, so they are perfectly able to continue working in the community," she wrote in a statement to NPR.

While that may be the case, critics warn such a set-up would leave birth workers of color at a clear disadvantage if the state ever moves to officially reimburse doula services through its Medicaid program.

Members of Cihuapactli say they're not opposed to creating more accessibility to doula services. They simply want a system that recognizes the barriers that marginalized people face when trying to pursue, or access, such care.

"I want to acknowledge that creating this system doesn't create any easy access for women," said Yvonne Ballesteros, a doula and member of Cihuapactli. "We're talking about marginalized communities ... We probably don't have a lot of Black, Indigenous, people of color who have access to the Internet, who have access to fax machines or scanners and all these different things that are needed for that."

Ballesteros is a proponent of an alternate system known as the promotora model, which works to create a system of local health workers by providing basic health training to people in underserved communities. For Cihuapactli, their focus has been on implementing the model through apprenticeship programs.

An alternate model

Apprenticeship is a practice that has been taken up by birth workers of color like Fatima Muhammad Roque — a Phoenix-based doula with more than 20 years of experience.

Before the pandemic, Roque led in-person training programs for women from diverse backgrounds from across the Phoenix area who aspired to become doulas. The program, she said, had a specific audience in mind: women who want to support other women, "especially women of color, especially women who have a need for support, for healing, for optimal outcomes."

In the year since the pandemic hit, Roque has used her time to launch the telehealth program Wellness Within Reach. The goal is to support families of color as they maintain the socially distanced, stay-at-home world of COVID-19. Roque has been following up with 30 families, which includes sessions tailored exclusively for fathers and children.

Following the program's trial run, Roque plans to meet with the Atlanta-based nonprofit Reaching Our Sisters Everywhere to submit a grant proposal to bring back her doula training program in a virtual format.

"I feel like this has brought people together in a different way," she said.

Meanwhile, Muhammad officially became a certified professional midwife last April. Since then, she has worked with 15 families and is already booked far into 2021. She has found ways to adapt, offering prenatal and postpartum sessions over Zoom and putting together telehealth kits for her clients: a thermometer, an automated blood pressure cuff and a fetal doppler that clients can use to listen to their baby's heartbeat.

She grinned from ear to ear as she recalled recently helping a Black woman give birth at home, in water. The husband had only joined his wife in the tub for a few minutes when he felt the baby's head. The wife, she said, had "the most peaceful, serene look on her face," Muhammed said. "Bliss, pure bliss."

It was at that moment Muhammad realized she was finally doing what she set out to do in the first place: returning the power she feels was taken from Black mothers back to them.

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