A Community‐Centered and Antiracist Model of Whole‐Person Perinatal Care: Beloved Birth Black Centering

Abstract

Beloved Birth Black Centering (Beloved) is a community‐centered and antiracist model of whole‐person perinatal care, created by and for Black people in Alameda County, California. In 2019, a diverse group of birth equity advocates within Oakland's public safety net health care system and public health department came together to design Beloved, following the leadership of Black midwives, public health practitioners, physicians, and doulas. Beloved centers the expertise and vision of Black women and birthing people while working to redefine Black perinatal care and transform Black birthing experiences and outcomes. Growing evidence documents Black women and birthing peoples’ experiences, needs, and preferences for perinatal care. They seek to be respected, heard, believed, the autonomy to make informed decisions, and have access high quality care and supportive resources. Beloved aims to center these needs and preferences and provide whole‐person perinatal care so Black women and birthing people not only survive—they thrive. Beloved bundles 5 evidence‐informed strategies (referred to as the Gold‐Package of Black Love) into its model of whole‐person perinatal care: midwifery‐led group perinatal care; racially‐concordant care; wrap‐around support; childbirth education; and doula services. Each evidence‐informed strategy has been referenced as a need and preference by Black women and birthing people and has been found to protect against at least one pregnancy‐related complication. The model aims to provide patients with holistic social support, high quality person‐centered care, and antiracist approaches to care. The founders of Beloved took an asset‐based approach and partnered with local community organizations and Black entrepreneurs to implement Beloved during the COVID‐19 pandemic despite the inherent challenges of innovating new models in under‐resourced, safety net health care systems. The model's development, implementation, theoretical underpinnings, and theory of change are described. Additionally, we discuss key lessons from implementation and future directions for research, quality improvement, sustainability, and community engagement.

INTRODUCTION

In 2019, a diverse group of birth equity advocates within the public safety net health care system and public health department in Alameda County, California came together to develop a community‐centered and antiracist model of whole‐person perinatal care called Beloved Birth Black Centering (Beloved). Beloved was created by and for Black people, with the leadership of Black midwives, public health practitioners, physicians, and doulas. Driven by their own lived experiences, Beloved's founders built Beloved by centering the needs and expertise of Black women, birthing people, and families. Beloved redefines Black perinatal care by uplifting Black joy and knowledge. Beloved operates at the clinical level to provide whole‐person perinatal care and is supported at the systems level by the Beloved Birth Collective, an independent nonprofit. Beloved bundles 5 evidence‐informed strategies, referred to as the Gold‐Package of Black Love, into perinatal care delivery: midwifery‐led group perinatal care, racially‐concordant care, wrap‐around support, childbirth education, and doula services. Beloved's vision is shown in Figure 1.

Figure 1.

Beloved's Vision

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Black women and birthing people are more likely to suffer and die from pregnancy‐related complications than their White counterparts. ¹ , ² These pregnancy‐related racial disparities persist beyond individual‐level factors (eg, income), ² and a growing body of research indicates racism as the root cause of health inequities. ³ Racism operates in several forms (eg, structural, institutional, interpersonal), is embedded within and across our systems (eg, health care, political, legal), and often co‐exists with sexism and genderism, to create a number of stressors (eg, discrimination, social determinants of health) for Black women and birthing people. ⁴ , ⁵ , ⁶ Studies show that these stressors influence physiologic processes in the body, increasing the risk for psychoneuroendocrine and inflammatory dysregulation. ⁷ The impact of this physiologic response and the body's adaptation to it can lead to increased allostatic load and weathering, leading to adverse health outcomes among Black women. ⁸ , ⁹ , ¹⁰ Pregnancy, childbirth, postpartum recovery, and the transition into motherhood are critical and sensitive periods in the life course, making them particularly vulnerable to stressors and their impacts. ¹¹ , ¹² Perinatal care visits offer several touchpoints with the health care system during this critical window of time, making it a logical opportunity to intervene for Black perinatal health and well‐being.

QUICK POINTS

• ✦Beloved Birth Black Centering (Beloved) is an innovative community‐centered and antiracist model of whole‐person perinatal care, created by and for Black people.
• ✦Beloved centers the expertise and vision of Black women, birthing people, and birth workers, while working to redefine Black perinatal care and transform Black birthing experiences and outcomes.
• ✦Beloved bundles 5 evidence‐informed strategies into perinatal care delivery, referred to as its Gold‐Package of Black Love: midwifery‐led group perinatal care, racially‐concordant care, wrap‐around support, childbirth education, and doula services.
• ✦Beloved's locally grown innovation serves as a model of how perinatal care services can be tailored and co‐designed with the community to improve experiences and outcomes for marginalized and disenfranchised people in the United States.

Clinical research has revealed several evidence‐informed strategies for Black perinatal health care, but to our knowledge, multiple combined strategies have not been implemented, sustained, and scaled in under‐resourced safety net health care systems in which a large proportion of Black families receive care. ¹³ Black women and birthing people have explicitly expressed a need and preference for whole‐person care, reporting the need for holistic social support (eg, social connections and community), quality and person‐centered health care (eg, respectful clinician‐patient interactions), and health care that is antiracist (eg, addressing the impacts of social determinants of health). ¹⁴ , ¹⁵ , ¹⁶ Beloved revolutionizes Black perinatal health care by bundling and implementing what Black women and birthing people are asking for.

The purpose of this article is to provide a comprehensive background of this innovative perinatal care model, including its development, implementation, theoretical underpinnings, and theory of change. We also discuss key lessons from implementation and future directions for research, quality improvement, sustainability, and community engagement. Outcome data will be disseminated in future peer‐reviewed publications and community impact reports.

THE INNOVATION: BELOVED BIRTH BLACK CENTERING

Conception and Development

Beloved was born from the shared commitment to achieve perinatal health equity in Alameda County, California. In 2019, Alameda County's public health department (ACPHD) and health care delivery system (Alameda Health System [AHS]) joined forces to create a more holistic model of perinatal care with the goal of addressing racial inequities in Black maternal health and helping Black families thrive. ¹⁷ , ¹⁸ AHS's Department of Obstetrics, Midwifery, and Gynecology had launched group prenatal care in 2004 using the CenteringPregnancy model, but a group of AHS's Black midwives saw the need to expand and adapt the model to better meet the needs of Black families. ¹⁹ Meanwhile, ACPHD's Maternal, Paternal, Child, and Adolescent Health EmbraceHer program hoped to expand its service model to meet client demand for more group‐based programming options and enhance service continuity during and between pregnancies for Black families. Both teams realized that by joining forces they had the unique opportunity to bring together Alameda County's public health and safety net health care services.

AHS's Centering and ACPHD's EmbraceHer team met regularly to conceptualize a group perinatal health care program that incorporated evidence‐informed strategies and was antiracist and community‐centered. The team was committed to flipping the script—moving from risk‐based stigmatization, the pathologizing of Blackness, and White‐centered program design masked as culturally‐neutral practice, toward an intentional community‐grown model by and for Black people that honors and celebrates Black birth, supports and fortifies Black families, and provides respectful evidence‐informed care.

By early 2020, founding members had conducted a needs assessment with Black families, developed a program design, and were ready to launch the model. Although Beloved's partnership with ACPHD and secured grant funding, AHS system‐level leadership decided not to launch the program because of AHS's significant financial hardship. Shortly thereafter, the COVID‐19 pandemic forced clinical operations at AHS and health care services at ACPHD to adapt to virtual operations when possible, and group prenatal care programs at AHS and around the country came to a halt. Because the COVID‐19 pandemic exacerbated existing maternal health inequities and with the racial reckoning following the police murder of George Floyd, Beloved's lead midwife and founding director advocated for the urgent need for health equity programs, leading to Beloved's implementation. In October 2020, Beloved was launched as a hybrid model, with Centering group visits and other evidence‐based components conducted virtually through Zoom and individual perinatal health care assessments in person at AHS. Beloved transitioned to an all in‐person format at an AHS clinic in East Oakland in September 2022.

Key Partners and Stakeholders

Beloved is co‐owned and operated by ACPHD and AHS and is made possible through an essential collaboration with the Beloved Birth Collective.

The ACPHD serves over 1.7 million residents in Alameda County, California. ¹⁷ ACPHD's EmbraceHer team of Family Support Advocates, who include community health workers and case managers, colead Beloved's group perinatal care model with AHS's clinical team. The Family Support Advocates cofacilitate group visits and provide wrap‐around support through care coordination, referrals, and help with addressing patients’ unmet health‐related social needs.

AHS is the only safety net provider that offers labor and birth services and CenteringPregnancy group prenatal care in Alameda County. An overwhelming majority of AHS's patients are low‐income and Black, Indigenous, and People of Color, coming from marginalized communities at greater risk for pregnancy complications because of racial inequities and economic inequality. ¹⁸

The Beloved Birth Collective was established in 2020 as a grassroots community collective to partner in creating Beloved and has grown into a nonprofit organization committed to the success of Beloved and the birth justice movement. As a vital partner, it plays a key role in Beloved's ongoing program design, quality improvement, and community engagement. At the systems level, it strengthens the community‐centered perinatal equity ecosystem, creating the conditions that make it possible to provide the Beloved model to residents in Alameda County.

Beloved collaborates with a variety of community partners and stakeholders to fulfill its mission:

Community organizations and businesses, particularly local Black‐owned businesses, entrepreneurs, and activists, are engaged to provide holistic wellness services, help raise funds, and support advocacy efforts with Beloved.

The AHS Foundation has provided grant‐writing and funds management services to Beloved since 2021. AHS Foundation advances health equity throughout Alameda County by securing funding and community support for AHS's strategic priority programs that reduce racial health inequities and improve health outcomes and well‐being. ²⁰

The University of California, Berkeley's Wallace Center for Maternal, Child, and Adolescent Health (Wallace Center) has been Beloved's research and evaluation partner since 2021. The Wallace Center is a multidisciplinary research center dedicated to advancing maternal, child, and adolescent health and to reducing health inequities with a focus on innovation and technology. ²¹

Evidence‐Informed Strategies

Beloved bundles 5 evidence‐informed strategies into perinatal care: midwifery‐led, group perinatal care; racially‐concordant care; doula services; wrap‐around support; and childbirth education (Table 1). Each evidence‐informed strategy has been referenced as a need and preference by Black women and birthing people or has been shown to protect against at least one pregnancy‐related complication. More information outlining each strategy's timing of delivery and a summary of evidence can be found in Supporting Information: Appendices S1 and S2.

Table 1.

Summary of Beloved's Evidence‐Informed Strategies

Evidence‐Informed Strategy	Summary
Racial concordance	Beloved's core team is Black; all facilitators of Beloved group care visits (AHS CNMs and ACPHD Family Support Advocates) are Black, as are the lead physician and wrap‐around providers (eg, doulas, photographer, lactation consultants, physical fitness trainer, massage therapist or bodyworker).
	Outside of the core team, Beloved groups are supported by racially diverse teams of clinicians and staff within AHS and ACPHD.
	Most patients choose to give birth at AHS's Wilma Chan Highland Hospital labor and delivery unit, where they receive intrapartum care from the racially diverse on‐call team.
Midwifery‐led, group perinatal care	Beloved is a community‐grown, Black Midwifery‐led adaptation of CHI's CenteringPregnancy, a person‐centered and evidence‐based model of group prenatal care.
	Patients receive 15 group perinatal visits (approximately 12 prenatal and 3 postpartum).
	Visits are moderated by 2 facilitators: a nonclinician who focuses on group flow and health education activities, and a CNM who provides perinatal care.
	Visits are typically 2‐3 hours long and include 8‐10 individuals in a cohort with similar pregnancy due dates.
	The facilitation approach is meant to improve patient‐clinician interactions and enable shared decision‐making. The essential elements of the CenteringPregnancy model include health assessments, education, and community building.
	The Beloved team maintains model fidelity to the essential elements required by CHI for licensure (ie, groups are facilitative rather than didactic, patients are active participants in their health assessment, etc.), but expands on the model by providing 5 additional visits (2 additional during the beginning of pregnancy and 3 additional visits postpartum), and bundles in Beloved's other evidence‐informed strategies.
Doula services	Patients who desire it are matched with a doula who provides up to 16 hours of 1‐to‐1 prenatal, intrapartum, and postpartum support.
	Doula services are provided at no cost to the patient by the Black Women Birthing Justice Doula Collective through a contract with ACPHD's Doula Services Program.
	Patients can tailor doula services to their wants or needs.
Wrap‐around support	ACPHD's Family Support Advocates, who include community health workers and case managers, provide personalized care coordination and connections and referrals to essential community resources.
	Community building during group perinatal care visits.
	Patients have free access to holistic wellness services, including: Postpartum meal delivery (weekly for 6 weeks postpartum) Fresh produce bags at every group perinatal care visit Access to one‐on‐one lactation/infant feeding specialist visits (unlimited number of visits) Exercise and movement classes (unlimited access; some occur right after group visits, and patients also have access to classes in the community) Prenatal and postnatal massages and bodywork (max of 3 appointments) Herbal wellness and birth supplies (bottom healing supplies, newborn supplies including diapers, infant feeding supplies) Calm app (unlimited access; subscription) ‐Referral to Blue Skies Mental Health & Wellness One pregnancy or postpartum photoshoot
Childbirth education	Beloved decided not to use CHI's patient education notebooks and instead opted to create custom childbirth education that reflects the community served and centers the topics that are important to them.
	The childbirth education materials and curriculum are written and illustrated by Beloved Birth Collective's midwives and artist, respectively.
	Materials include education handouts and interactive worksheets that aim to celebrate Black birthing families while de‐pathologizing Blackness and equipping patients with the information and tools needed for shared decision‐making and informed consent.
	Materials are rooted in the Reproductive Justice, Birth Justice, Womanist theory, Intersectionality, Tricia Hersey's “rest as resistance” and “rest as reparations 28 ,” and the Superwoman Schema 29 frameworks.
	The curriculum includes culturally‐reverent activities, such as Nap Ministry Rest Deck cards, and facilitated discussions using the Superwoman Schema framework.

Abbreviations: ACPHD, Alameda County Public Health Department; AHS, Alameda Health System; CHI, Centering Healthcare Institute; CNMs, certified nurse‐midwives.

Theoretical Foundations

The Beloved model is informed by and incorporates several theoretical frameworks. Reproductive justice and birth justice, the recognition that access to safe, dignified, and compassionate perinatal care and that birthing support is a human right, are central to Beloved's mission and vision. ²² Beloved honors the rights of families to decide if, how, where, and with whom to give birth and recognizes their right to raise the children they give birth to in safe and supportive communities. Beloved acknowledges the role of intersectionality in the experience of reproduction in that oppression because of race, gender, class, and sexual identity is integrative. ²³ Beloved actively aims to address obstetric racism, a term and intersectional framework developed by Dr Dana‐Ain Davis that describes how Black birthing people face various forms of medical mistreatment and discrimination during reproductive care because of their intersecting identities as both patients with perinatal needs and Black individuals. ²⁴

Beloved embraces Womanist theory and incorporates culturally‐reverent care, a term coined by Leseliey Welch to describe community‐centered practices grounded in love, safety, and trust that respect and uplift cultural identities. ²⁵ , ²⁶ Beloved's approach to providing safe and supportive care is informed by midwife Jennie Joseph's JJ Way model of care—a model that creates perinatal safe spots to protect against materno‐toxic areas by using a trauma‐informed, team‐oriented approach. ²⁷ Beloved incorporates Tricia Hersey's “rest as resistance” and “rest as reparations” into group care activities and childbirth education materials with the goal of supporting patients’ holistic wellness in pregnancy and postpartum while also strengthening their ability to resist the violent and oppressive systems that are weathering Black women, birthing people, and families. ²⁸ Further, Dr Cheryl Woods‐Giscombe's Superwoman Schema framework is used within Beloved's group care curriculum and childbirth education to help patients understand how many African American and Black women experience stress and to provide self‐care practices grounded in mindfulness, resilience, and self‐compassion to help African American and Black women live a life of joy and greater well‐being. ²⁹

Theory of Change

In 2023‐2024, Beloved developed a theory of change (ToC) by engaging Beloved's entire ecosystem in a codesign process centered on the experiences and expertise of Beloved's alumni. This work included an alumni focus group (n = 11), alumni surveys (n = 36), an Outcomes Summit that brought together all of Beloved's stakeholders, and a final series of collaborative debriefs with the Wallace Center. Beloved's ToC is found in Figure 2 and is illustrated as a circle to emphasize the model's community‐centered approach. The circle moves from the outside in through 5 yellow gradient layers. The outermost layer depicts how a community‐centered perinatal equity ecosystem creates the conditions that make it possible to provide the Beloved model. The second layer lists the 5 evidence‐informed strategies for whole‐person perinatal care. The third layer outlines the hypothesized mechanisms of how these evidence‐informed strategies lead to the outcomes and impact of the model, which are shown in the 2 innermost layers. Additional details about the hypothesized mechanisms can be found in Supporting Information: Appendix S3.

Figure 2.

Beloved's Theory of Change: A Community‐Centered and Antiracist Model of Whole‐Person Perinatal Care

Abbreviation: SDOH, social determinants of health.

IMPLEMENTATION

Recruitment and Enrollment

Interested women and birthing people can opt in to receive Beloved as their routine perinatal care at AHS. During prenatal intake visits, clinicians are trained to introduce Beloved and to create referrals for interested patients, who are then contacted directly by the Centering team. Patients who opt into Beloved are grouped into cohorts of approximately 10 patients with similar due dates and begin Beloved's group perinatal care model between 16‐ and 20‐weeks’ gestation. Beloved initially enrolled one cohort every 2 months but moved to monthly cohorts in September 2023 because of high patient demand. As of December 2024, Beloved has launched 34 cohorts and has served over 330 women and birthing patients who self‐identify as Black.

Funding

As of 2024, Beloved operates with an annual budget of approximately $3 million across various funding streams. AHS covers the cost of clinical facilities, infrastructure, and personnel. ACPHD invests a large amount of resources (approximately $1.4 million annually) in Beloved thanks to funding from the federal Healthy Start Initiative, California's Perinatal Equity Initiative, and other public funding streams. These ACPHD funds pay for EmbraceHer's wrap‐around support, including supplies, staffing, doulas, and mental health specialists, in addition to the leadership and administrative time for Beloved's director, who is a certified nurse‐midwife. Beloved also receives philanthropic funding from individual donors and foundations, most of which are unrestricted grants gifted from a trust‐based philanthropy perspective. Many of these grant funds are used to pay for Beloved's holistic wellness services and capacity‐building initiatives.

DISCUSSION

Public health systems have a moral obligation to reduce racism‐based perinatal health inequities, offer evidence‐informed care, and be accountable to community needs. To achieve substantial improvements in perinatal health outcomes, health care systems must significantly transform current health care models, with leadership and direction from the communities most impacted by perinatal health inequities.

Beloved's initial needs assessment in 2019 and the ToC development in 2023‐2024 were both carried out using a community codesign process that centered the expertise of Black women and birthing people while reflecting the input and contributions of a broad range of stakeholders. Beloved's innovations and success are thanks to the expertise of Black women, birthing people, and birth workers, and their willingness to engage in a community‐centered codesign process. This approach has facilitated a clear roadmap for Beloved and a vision of continuous quality improvement and innovation. Beloved is currently forming a Beloved Alumni Council that will meet regularly to partner on ongoing quality improvement, including co‐designing childbirth education materials and Beloved's expansion to well‐child and postpartum group dyadic care.

A key strength of Beloved's model is its county‐wide collaboration between ACPHD and AHS, and its strong Black leadership within these organizations. This partnership has allowed Beloved's visionary leaders to leverage the existing infrastructure and resources within ACPHD to address social determinants of health and within AHS to address clinical health care needs. Establishing data‐sharing agreements and contracts between AHS and ACPHD was a key requirement for developing this partnership and was made possible by working closely with the appropriate stakeholders and legal teams at each organization. Although this collaboration is one of Beloved's greatest foundational strengths, it's also one of Beloved's biggest challenges. ACPHD and AHS are both very large institutions that can be anachronistic, complex to navigate, and resistant to change. Safety net health care institutions are recognized for their mission‐driven clinicians, who are deeply committed to addressing racial health inequities, and for having a higher proportion of providers from a diverse range of racial and ethnic backgrounds. However, these institutions are often constrained by limited resources, which can hinder innovation. As a team developing an innovative model of care through a community‐centered codesign process, Beloved's founders needed the time and resources to envision new ways of providing care, the freedom to implement different ideas, and the flexibility to adapt to evolving community needs. Beloved's founders have worked to overcome these system‐level barriers by creating the Beloved Birth Collective, an independent nonprofit that allows them to build from the bottom up with a broad, grassroots coalition while winning support from high‐level leadership at AHS and ACPHD. To our knowledge, no other US perinatal care program is co‐owned and co‐operated by the county's public health department and health care delivery system and is made possible by collaborating with a grassroots community collective.

The sustained efforts of institutional champions and the use of innovative strategies to navigate bureaucratic challenges have been essential for the implementation and sustainability of Beloved. AHS has a Centering Group Care Steering Committee that is made up of multiple key leaders and stakeholders across all of Beloved's partnership organizations. This committee meets quarterly and serves as a forum to build alignment and troubleshoot challenges. The committee has enabled creative solutions to institutional barriers and has created shared accountability to advance operational work and advocacy initiatives. In 2023, the committee supported AHS to become the first US health care system to receive system‐wide certification from the Centering Healthcare Institute, streamlining services and resources across clinical locations to facilitate scaling Centering programs.

The partnership between Beloved and AHS Foundation was instrumental in securing short‐term and medium‐term funding agreements for its launch and implementation. Establishing a robust partnership with a primary philanthropic supporter that offers dedicated assistance in identifying and applying for funding is critical, as safety net health care institutions and public health departments often lack the necessary time and resources to undertake this work. The funding secured with the help of AHS Foundation was critical for providing services that are not covered by Medi‐Cal's current reimbursement infrastructure but are necessary for whole‐person care, including holistic wellness services (eg, postpartum meal delivery). Beloved is partnering with an external consultant to create a comprehensive financial sustainability plan, which includes identifying opportunities to improve the coding and billing of Beloved's services. The resulting financial insights, including detailed cost frameworks and payment mechanisms, will be disseminated to help guide other communities in adopting the model. In general, the long‐term financial sustainability of whole‐person care models, like that of Beloved, will require health care payors and purchasers to move toward value‐based or alternative payment models that better align incentives between all stakeholders.

Several research and quality improvement efforts are on the horizon. Beloved is developing an antiracist birth equity advocacy toolkit to support communication and dissemination of the model by stakeholders. Given Beloved's success, the team is also developing an implementation toolkit to support other communities in successfully applying the evidence‐informed strategies to their local context. The Wallace Center is conducting a robust evaluation, assessing how Beloved impacts pregnancy‐related clinical health outcomes and experiential outcomes. Clinical health outcomes are collected via AHS's electronic health record system. Experiential outcomes are collected via 2 surveys: an anonymous program feedback survey and a survey measuring autonomy in decision‐making and respectful treatment in perinatal health care. ³⁰ Future publications, including a community impact report, will report on these findings.

CONCLUSION

Beloved offers a paradigm shift by empowering Black women, birthing people, midwives, and the broader birth equity community to lead health system innovation and redefine perinatal care for the Black birth justice movement. Beloved's locally grown innovation serves as a model for how to address the national crisis of racial health inequities impacting the Black community. It also serves as an example of how perinatal care services can be adapted and co‐designed with the community to improve experiences and outcomes for other marginalized and disenfranchised people experiencing health inequities in the United States.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

Supporting information

Appendix S1. A Summary of Evidence on Beloved's Evidence‐Informed Strategies

Appendix S2. The Timing of Delivery for Beloved's Five Evidence‐Informed Strategies

Appendix S3. Description of Mechanisms in Beloved's Theory of Change