Melanated Group Midwifery Care: Centering the Voices of the Black Birthing Community

Abstract

Access to safe and dignified pregnancy, childbirth, and postpartum experiences is a fundamental right for all pregnant and postpartum people. In the United States, systemic racism fuels distrust and disengagement in a health care system that continues to dehumanize the Black community. The respectful maternity care literature explains how these systemic, structural, and institutional failings produce maternal health disparities and expose a pattern whereby Black women receive less adequate maternity care. The implementation of trustworthy policies and practices is urgently needed because no single intervention has or will substantially reduce maternal disparities. The purpose of this article is to describe a multicomponent maternity care innovation, Melanated Group Midwifery Care (MGMC). MGMC was codesigned with community partners and is responsive to the needs and desires of Black women, making MGMC a culturally adapted and patient‐centered model. Racial concordance among care providers and patients, group prenatal care, perinatal nurse navigation, and 12 months of in‐home postpartum doula support are 4 evidence‐based interventions that are bundled in MGMC. We posit that a model that restructures maternity care to increase health system accountability and aligns with the needs and desires of Black pregnant and postpartum people will increase trust in the health care system and result in better clinical, physical, emotional, and social outcomes.

INTRODUCTION

In the United States, maternal mortality rates are 3 to 4 times higher for Black women than white women. ¹ At every point along the pregnancy continuum, Black women experience more severe maternal morbidity. ² These disparities persist regardless of age, income, and education. ³ Black mothers also experience disrespectful and discriminatory health care, ⁴ , ⁵ , ⁶ , ⁷ , ⁸ have alarmingly low rates of adequate and high‐quality perinatal care, and have insufficient coordination with mental health services, specialty care, and wrap‐around services, especially during the postpartum period. ⁹ , ¹⁰ These systemic failings, on top of racism, reinforce feelings of distrust and disengagement, exposing societal mechanisms driving the disparities in maternal morbidity and mortality. ¹¹

High levels of distrust and disengagement in health care originate with a health care system that has historically dehumanized the Black community. ¹² , ¹³ , ¹⁴ , ¹⁵ Higher exposure to structural racism is consistently associated with adverse perinatal and birth outcomes among pregnant Black women. ¹⁶ In the United States, structural racism has been historically used to advantage white people over Black people in society through the implementation of discriminatory practices demonstrated to limit access to housing, quality education, wealth, employment, and disproportionate incarceration rates. ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰

The predominance of white midwives in the US health care system also contributes to the distrust, disengagement, and systemic failings that underlie alarming Black maternal mortality and morbidity rates. In 2021, the majority of certified nurse‐midwives/certified midwives identified as white (84.9%). Midwives who identified as Black or African American were the next most common group at 7.3%, which represents a small increase in the number of midwives who identify as Black or African American from the 2020 report (6.9%). Other self‐reported people of color comprised less than 5% of the total midwifery workforce. ²¹

Continuing education (CE) is available for this article. To obtain CE online, please visit http://www.jmwhce.org. A CE form that includes the test questions is available in the print edition of this issue.

Quick Points

• ✦Melanated Group Midwifery Care (MGMC) is a radical reconfiguration of perinatal care designed to deliver trustworthy care that centers the voices of Black women, increase shared decision‐making and engagement, and ultimately eliminate maternal health disparities.
• ✦The 4 evidence‐based strategies of MGMC are (1) racial concordance between Black midwives and patients, (2) group prenatal care, (3) nurse navigation, and (4) one year of in‐home postpartum doula support.
• ✦MGMC has great potential for impact because it is a midwifery‐led intervention that activates maternal mortality review committee evidence to address the specific barriers faced by Black mothers who experienced morbidity and mortality.
• ✦If Black women trust Black midwives, more collaborations with community partners are crucial to generate and support educational and professional pipelines for Black, Indigenous, and people of color midwifery students.

The impact of racism on health outcomes is exemplified in Chicago, the third largest city and one of the most racially segregated cities in the United States. ²² Chicago represents a large proportion of the national burden of maternal mortality and severe maternal morbidities. In 2015, non‐Hispanic Black women in Chicago were 3 times as likely as non‐Hispanic white women to experience a pregnancy‐associated death and 6 times as likely to die from a pregnancy‐related cause. ²³ , ²⁴ This Black‐white disparity is higher than the national estimate ³ and increases with age. The recent closing of hospital labor and delivery units across the city's South Side exacerbates risks faced by Chicago's Black community. ²⁵ , ²⁶

To address maternal health disparities, Illinois established 2 maternal mortality review committees (MMRCs) that review all maternal deaths up to one year postpartum to identify contributing factors and learn where to take action to improve care. In their 2021 report, the MMRCs identified multiple common factors contributing to pregnancy‐related deaths and severe perinatal morbidities, including discriminatory health care, distrust of and low engagement in perinatal care, lack of coordination and continuity among health care providers, and barriers to access mental health, social support, and crucial wrap‐around services particularly in the postpartum period. ²⁴ These inequities are grounded in structural racism that is enacted within health care institutions that are predominantly white and disadvantage Black women. ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²⁷

A model of maternity care centered on the needs of Black women ¹ , ⁵ , ¹⁰ , ¹⁸ that is also inclusive of broad structural changes to attenuate the impacts of structural racism does not exist; therefore, radical health care reconfigurations are needed to create trustworthy care that center the voices of Black women, increase shared decision‐making and engagement, and ultimately eliminate disparities. The authors describe the scientific rationale, implementation, and significance of the multicomponent maternity care innovation designed to fill this gap, Melanated Group Midwifery Care (MGMC). With funding from the Patient Centered Outcomes Research Institute, MGMC was launched as part of a randomized control trial in which it is being compared with traditional perinatal care at a large academic medical center in Chicago. We are collecting data from the electronic health record on patient engagement (eg, completed prenatal visits, adherence to care recommendations, and referrals for medical and social services), perinatal outcomes (eg, complications, breastfeeding, Apgar scores, and birth weight), and validated surveys on patient trust, activation, social determinants of health, and mental well‐being. Finally, qualitative interviews are being conducted to (1) evaluate the barriers and facilitators to implementing MGMC and (2) trace the care pathways of participants in both MGMC and the control group who experience adverse maternal outcomes. This study will provide evidence on how 4 culturally adapted, evidence‐based interventions synergystically impact patient engagement, decision‐making, and outcomes across the pregnancy continuum.

THE INNOVATION: MELANATED GROUP MIDWIFERY CARE

MGMC's multipronged approach addresses the complex interactions among social determinants of health, societal drivers of inequity, health care systems, implicit bias for health professionals and the importance of engaging with the community. The 4 evidence‐based strategies of MGMG are (1) racial concordance between Black midwives and patients, (2) group prenatal care, (3) nurse navigation, and (4) one year of in‐home postpartum doula support.

With these components, MGMC integrates lessons learned from the state of Illinois’ systematic review of hundreds of cases of women who suffered severe maternal morbidity and mortality. MGMC also focuses on prenatal and postpartum care (the periods in which most preventable maternal deaths occur) and on actionable institutional factors to attenuate the specific effects of structural racism impacting Black women within the health care system. MGMC engaged community partners at this project's inception to ensure MGMC is designed to aligne with community priorities and can help to sustain engagement and interest among those most impacted. ¹⁴ , ¹⁷ The model is responsive to the needs and desires of Black women, making MGMC a culturally adapted and patient‐centered model. MGMC aims to reconfigure maternity care to be trustworthy in ways that will save lives.

Concordant Care

Black women want racially concordant care. When asked how to improve perinatal care so that they feel safer, Black women have consistently requested Black health care providers. ²⁸ , ²⁹ Patient‐centered research on maternal mortality includes acknowledging that Black women have unique expertise, skills, and perspectives that should be the center of intervention design, development, implementation, and evaluation. ⁵ Racial concordance between patients and providers facilitates cultural sensitivity and trust‐building in ways that increase patient satisfaction and engagement and may improve health outcomes. ²⁸ , ²⁹ For Black families, it can also save lives. ²⁹ A study of nearly 1.8 million neonates showed that patient‐provider concordance halved the racial disparity in neonatal mortality, showing that racial concordance can be especially impactful. ²⁹

MGMC integrates racial concordance into all components to improve maternal trust, engagement, or outcomes. Black midwives and Black nurse navigators will cofacilitate a prenatal group of 8 to 10 Black pregnant patients. After birth, the patients will continue to be supported for up to 12 months postpartum by their Black nurse navigator as well as a Black community doula. Through a partnership with Melanated Midwives and Chicago Birthworks Collective, community stakeholders, and Black women, each intervention was adapted to align with the interests of Black pregnant people, including concerns about maternal morbidity and mortality.

Group Prenatal Care

Group prenatal care fundamentally alters service delivery, allows for longer, person‐centered care, and can potentially address the demands for community engagement and higher quality care. Group care models are a strategy with well‐documented efficacy and engagement for Black mothers, achieving a 33% reduction in preterm birth and 44% among high‐risk women. ³⁰ Group health care disrupts power hierarchies, uses interactive learning, and builds social support and community. ³⁰ , ³¹ Additional outcomes include positive impacts on prenatal and postnatal care visit experience, attendance, and satisfaction; better prenatal mental and physical health and breastfeeding behaviors; and more contraceptive uptake to lengthen birth intervals. ³²

This study will provide evidence on how group prenatal care impacts patient engagement, decision‐making, and outcomes. In MGMC, Black pregnant patients will attend 10 prenatal sessions and 1 postpartum session of group care that were adapted for the Black birthing community. The content relays knowledge about pregnancy‐related warning signs and provides evidence‐based tools to help women speak up and have life‐saving conversations with maternity care providers when concerns about their well‐being arise.

Care Coordination

Decentralized and uncoordinated maternity care exposes cracks in the health care system and places excessive burdens on Black women. Women with comorbidities are at higher risk of developing complications during pregnancy. However, referrals to high‐risk obstetrics, mental health, and other medical specialties are burdensome and complex, often requiring multiple calls, appointments, transportation, and childcare. Coordinating mental health and specialty care with prenatal and postpartum care is crucial to providing safe and effective maternity care. Women who require complex care collaboration often face barriers to comprehensive, integrated care. The Illinois MMRC providers have noted that women who die often present to emergency rooms multiple times with concerning symptoms. ²⁴ However, because of inaccurate recognition of complex symptoms, lack of a coordinated care plan with obstetric providers, and racism, clients’ needs are not met. Research suggests that nurse navigation may attenuate these risks by providing continuity and care linkages to support a range of positive outcomes including increased engagement with perinatal care, improved management of complications and comorbidities, decreased preterm delivery, and reduced frequency of emergency admissions. ³³ , ³⁴

Evaluation of MGMC will provide evidence about the impact of nurse navigation on access, engagement, and follow‐up care for women with complex medical and social needs. In MGMC, a Black nurse navigator will cofacilitate each group prenatal session and communicate regularly with the postpartum doulas. The nurse navigator will also maintain regular communication with participants throughout the prenatal and postpartum periods to assess needs, facilitate referrals, and ensure wrap‐around services. The goal is to provide proactive and extensive referrals (warm handoffs, such as transferring care between 2 members of the health care team in front of the patient) and follow‐up to improve patient activation and engagement through shared decision‐making and positive communication.

Postpartum Doulas

Women are often neglected by the health care system once they give birth. Health system distrust follows Black women from pregnancy to postpartum care, when they may be at increased risk of receiving insufficient support, coordinated care, and wrap‐around services. One‐third of maternal mortality occurs during the postpartum period, ² , ²⁴ demonstrating great need for intervention. Postpartum in‐home visitation is a key recommendation from the Illinois MMRC. ²⁴ Postpartum doulas have been shown to increase patient engagement in mental health services and decrease postpartum depression. ³⁵ Those who work with doulas also have better breastfeeding practices, improved bonding with their infant, and a sense of control should complications arise. ³⁶ , ³⁷

MGMC evaluation will provide evidence on whether a trusted postpartum doula can successfully support postpartum women and facilitate the integration of mental health and medical services and planning. In MGMC, Black doulas with a well‐established relationship in the community will provide each participant with up to 70 hours of postpartum doula support for 12 months following birth. The postpartum doulas receive evidence‐based training with Chicago Birthworks Collective and Melanated Midwives on postpartum health promotion, recognition of warning signs, and methods for referral and follow‐up. They also meet regularly with the nurse navigator and midwives to facilitate peer support, mentorship, and integration into the health care system.

DISCUSSION

Nearly 83% of pregnancy‐related deaths in Illinois are preventable, ²⁴ reflecting many missed opportunities. Engagement in adequate prenatal care and detection of complications with timely intervention can alter the negative cascade leading to fewer mortalities and morbidities The Black Mamas Matter Alliance describes how “the lack of consideration of structural factors leads to systematic underestimation or misappraisal of Black Mamas’ clinical risk factors and the lack of consideration of structural factors increases risks.” ^{38 (p 398)} In other words, singular, targeted interventions are unable to address the multidimensional weaknesses that underlie maternal mortality. This effectiveness implementation study will be the first to test the impact of a revolutionary and multilevel intervention across the pregnancy and postpartum continuum.

This midwife‐led innovation has great potential for impact because it activates MMRC evidence to address the specific barriers faced by Black mothers who experienced morbidity and mortality. To address racial disparities in maternal health, a shift in the paradigm is needed to ensure that health systems and players within these systems deliver respectful care. Health systems and clinicians must recognize that health and well‐being have more to do with social and environmental factors than clinical issues. It is imperative that maternal health researchers focus less on targeted intrapartum interventions and patient adherence and more on the integration of structural change, including policies, systems, and environments that will meet the defined needs of Black women.

Additionally, more collaborations with community‐based organizations such as Melanated Midwives and Chicago Birthworks Collective is essential to addressing diversification of the birth workers. Melanated Midwives’ mission is to provide education, mentorship, and annual scholarships to Black, Indigenous, and people of color student‐midwives to offset the financial burden that comes with attending midwifery school and matriculating into the midwifery profession. For MGMC to be sustainable and scalable in meeting the needs of Black mothers, racial and ethnic representation must increase in midwifery education and practice. Birthing people should be able to choose providers whom they trust. If Black women trust Black midwives, more Black midwives are needed. In MGMC, we partnered with the University of Illinois at Chicago College of Nursing to support the racial and ethnic diversification of midwifery. Through this partnership, MGMC providers are working to develop an educational pathway program for Black doulas and medical assistants to become certified nurse‐midwives, create dedicated training opportunities for Black midwifery students to improve health equity in their communities, and offer clinical opportunities with the largest and most diverse midwifery practice in the Midwest.

In conclusion, MGMC is a new midwifery‐led model of care that respectfully promotes pregnant people's engagement in their care and positive provider‐client interactions. Our comprehensive and community‐engaged innovation addresses multiple needs of individuals in a context of high morbidity and mortality. Group prenatal care, racial concordance of health care providers and patients, nurse navigation, and postpartum doulas have each been shown to improve the quality of care and health outcomes. In this rigorous investigation of MGMC, a paradigm‐changing and transformative model is being implemented to improve maternity care quality without a major increase in staff or resources. MGMC staff will continue to collaboratively engage with Black women in the community about the model design, implementation, and interpretation of results. This study will provide rigorous evidence documenting whether a MGMC model is effective and should be replicated, tested in other contexts, and broadly adopted nationwide.

CONFLICT OF INTEREST

The authors declare no conflict of interest.