A BLACK WOMAN is nearly twice as likely as a White woman in Massachusetts to die during pregnancy or after childbirth, according to a 2014 report by the Department of Public Health. Nationally, the maternal mortality rate is more than twice as high for Black women as for Whites, according to the Centers for Disease Control and Prevention. Yet Black women seeking options for care during pregnancy and childbirth beyond a typical hospital birth, such as delivery with a midwife, may find few providers who look like them and come from their communities.
Nothing underscores that more this astounding reality when it comes to finding a Black midwife trained to oversee a home delivery: Stephanie Johnson is the state’s only Black home birth midwife.
Midwives are health care professionals trained to handle labor and delivery for lower-risk pregnancies in healthy women.
Johnson, 46, lives in Dorchester and runs Roots Midwifery out of her home. She graduated from Birthwise Midwifery School in Maine, apprenticed in the field, and is preparing to take a certification exam administered by the North American Registry of Midwives. (Certification is not currently required in Massachusetts, although a bill that would require home birth midwives to be certified is pending in the Legislature.)
Johnson, a member of a new legislatively-created commission on racial inequities in maternal health, said there are other Black doctor and nurse midwives in Massachusetts who practice in a medical setting, but as far as she knows, she is the only currently practicing Black home birth midwife. Nationwide, Johnson said roughly 10 to 13 percent of midwives are people of color, and only 5 percent are black. Only a small number of midwives specialize in home births.
CommonWealth spoke with Johnson about why there are so few Black midwives, how racism is at the root of higher maternal death rates among Blacks, and common misconceptions about having a home birth with a midwife (they arrive with extensive medical training, not with incense and candles). What follows is an edited version of our conversation.
COMMONWEALTH: What led you to become a midwife?
STEPHANIE JOHNSON: I always say I didn’t choose midwifery, midwifery chose me. I’ve always loved working with babies and pregnant woman. When I was a teenager, I wanted to be a pediatrician. Once I realized the schooling that was involved, I was like, I don’t know if I want to be in school for 12–plus years. At the time, I didn’t know what home birth was, I didn’t know about midwifery.
I had my first daughter at age 20 and started UMass Boston. Someone mentioned there was a 2.5-year wait for nursing school, and being a young mom, I just wanted to get in and get out. I ended up leaving UMass. When I started approaching age 30, I thought about going back to nursing school. I went to Roxbury Community College, and I didn’t like it. I have more of a holistic type of approach of how to do things. It just seemed really regimented. I ended up switching majors again and got a social science degree.
I still wanted to work within the community in birth work, so I became a doula, I became a certified lactation consultant, I became a childbirth educator, and I started my doula practice. I did that for about four years then started working at Mattapan Health Center. That really heightened my passion for this work. I went back to school to Curry College for a community health and wellness program.
My mentor Shafia Monroe was like, ‘Why not become a midwife?’ I’m like, because I was approaching 40 at the time, I’ve been in school for 10 to 15 years, I’m over it, I’m tired of being in school, it’s too late, that time has passed. She, in her motherly way with a stern voice, was, like, no, the calling for midwifery was for women who were well-known in the community, who already had children, who had experience, who had a lot to give and share in the community. I was a little hesitant at first, but I said okay.
CW: Were there other Black midwives around Boston?
JOHNSON: Boston had a thriving home birth practice of midwives in the 70s and 80s before it fizzled out in the Black community. Many of them have passed on or have moved away. At the time I didn’t know a whole lot of Black midwives.
CW: What’s involved in becoming a home birth midwife?
JOHNSON: There are maybe seven to 10 programs across the country. Birthwise stood out because it’s close. It’s about three hours away [in Bridgton, Maine]. They had a community program where I’d go to campus every 10 to 12 weeks, stay there two weeks, then come back home. It didn’t take me away from my daughter, and if I needed to work, I can do that. I got a full scholarship.
CW: Why are there so few Black midwives?
JOHNSON: Mainly it is financial. The cost of the programs is a barrier, finding preceptorships [apprenticeships] and getting a preceptor is a barrier. Most of us want to be with a preceptor that looks like us, that’s in our community, and there’s not a lot. Finding schools [is a barrier]. I think there’s under ten schools.
The majority of us are single moms or people who have families, so we have to work. In our apprenticeship, typically with a preceptor you’re on their schedule, being on call 24 hours, 7 days a week, 365 days a year. The majority of us would not be able to hold a full-time job. If you have someone who has a family and roof to put over their head and bills to pay, that poses a significant burden. You’re expected to do an apprenticeship sometimes for many years without being paid. I was fortunate the apprenticeship I was in allowed me to work part time, I was also privileged I was able to come back home and live with my parents. And my kids are older. My youngest at the time was 10 or 12, my oldest had moved out of the house.
CW: Does it matter whether a midwife helping a Black woman is Black, White, or any other race?
JOHNSON: It doesn’t necessarily. But for the Black community, particularly with everything that we are dealing with currently, it’s important. I understand the culture. I understand what they are going through. I have a different perspective. I can listen. I value what they have gone through and what they say. Culturally, we seek what we’re familiar with.
CW: Are Black families less likely have a home birth or to rely on birth aides like doulas?
JOHNSON: Before COVID I would have said maybe. But after COVID I would say not so much. COVID and the attention to the maternal health crisis has really heightened Black families’ desire to start looking for alternatives. My practice is full. The only reason why there aren’t more Black families seeking home birth primarily is financial. It’s an out-of-pocket expense, it’s not covered by insurance.
CW: What does a home birth cost?
JOHNSON: Between $4,000 and $6,000 is the average in the state.
CW: Are there differences between Black and White culture with regards to childbirth?
JOHNSON: In some respects, yes. Because so much is happening currently with Black maternal health and mortality, things are shifting. Before it was, like, I’m pregnant, I’m going to call my [obstetrician] or midwife, I’m going to go in, and whatever happens, happens. Now, because there’s so much attention to what’s happening with how you’re being treated, not being listened to, being mistreated, the trauma in medical settings, people are realizing we have a choice and we have options. What we’re finding, especially with COVID, [is] people are researching their options, which is why home birth is becoming more prevalent and becoming more of an option for more Black families.
CW: How do you make sure home birth is safe?
JOHNSON: People think that we show up with incense and candles for a home birth. That is not what happens. We are trained professionals. I’m certified in neonatal resuscitation, basic life support. I do carry medications to stop hemorrhaging, IV support. We are trained in normal physiological birth. Because we do not have the capacity to manage a full-on emergency, our job is to monitor very closely throughout the prenatal and birth process and to recognize anything that trends outside of normal. When that happens, we try to correct things in a very short amount of time, and if we are unable to…then we have a conversation with the client, let them know this is what’s happening, that we think, whether it’s mom or baby, they’re not tolerating the process well, and it’s time to make a plan B. That plan B is to transfer into whatever hospital we discussed prior to the labor process. We have a plan of what hospital we want to transfer to, what an emergency could look like, so they are prepared.
Home birth midwives are trained for normal, low-risk pregnancies, and my goal is to have a healthy pregnancy, healthy mom, and healthy baby.
CW: Statistics have shown there is a racial disparity in how many Black versus White women die of pregnancy or childbirth-related causes. Why is this?
JOHNSON: Racism. Racism is the cause. Black women are not being listened to. There’s this perceived notion we have a higher pain tolerance, we don’t need medications at certain points when we’re asking for it. We’re constantly under stresses with not being listened to, we’re dealing with insecurities of food, of housing, of being mistreated at work, looking at TV and every time we turn around seeing a cop shooting someone in the street, our children not being safe every time they walk out the door. That is internalized stress, it increases our blood pressure, increase our stress hormones, etc. These things are being transferred to our bodies and within our systems.
Part of the problem is everyone is treated the same in a medical setting. Everyone is getting the same testing, the same conversation, the same treatment across the board no matter what. Now with telehealth, especially with COVID, people weren’t being seen for long periods of time. A lot of people were seeking home births, saying, I have questions, I have concerns, I haven’t seen my providers for weeks or months. They’re disconnected from their partners, going to appointments by themselves, and feeling like they’re alone in those appointments.
When we look at the crisis that’s happening, it’s not just one thing. But racism is a part of it. As a Black woman, you’re looked at as a Black woman first and then all the other pieces are included in that.
CW: What do you mean?
JOHNSON: For some providers, as soon as you walk in the doors as a Black woman you’re automatically looked at as a risk factor for hypertension, preeclampsia, diabetes. You are probably going to be induced at 39 weeks because you’re high risk. Your experience is automatically jaded because you’re a Black woman, because the statistics show you’re possibly going to have a poor outcome because you’re a Black woman.
CW: What can be done to change that?
JOHNSON: There are a bunch of initiatives that are being done now to put systems in place to change protocols and bias trainings and things like that. Personally, I don’t think things are going to change until we get to the root of the problem. If I feel a certain way about someone, I can go to those trainings all day, it can go in one ear, out another. I personally think we need to start holding hospitals and providers accountable. So when patients have these experiences, they need to start reporting them.
Hospitals take their reputation very seriously. Until we as consumers are standing up and able to voice that we’ve had enough and we need to see changes, things are going to continue as is.
CW: You’re on a new state committee looking at racial inequities in maternal health. What do you hope to accomplish?
JOHNSON: I’m hoping to see some of these things change. We had a little bit of a rough start. There was a lot of miscommunication, people weren’t sure what was the goal, the structure. Now that we’ve gotten past that, now that we’ve gotten a structure and outline, we can put everyone’s goals together and start creating a task list to get those goals met.
CW: Is there anything else you want to add?
JOHNSON: I think that [home birth] is definitely an option for many Black families particularly, because you have a midwife who is going to understand your needs, who’s going to value not just your voice but your experience and your culture and your desires. It’s something that’s often lost in a medical setting. And it’s a family-centered type of care. With me doing visits in the home, siblings can be part of the care, your partner, husband, or boyfriend can be part of appointments. This isn’t just me being a provider, this is me coming into your space, being trusted in this space, not just for the couple but also with the family. This is a sacred moment in these people’s lives, and I want this to be not just a sacred time but also at transformative time that they’re going to remember.