Countless studies and extensive reporting over the last decade have laid bare a sad truth: The state of maternal health care in America is profoundly inadequate. That’s especially true here in Massachusetts. A study released last year by the Massachusetts Department of Public Health revealed that rates of severe maternal health complications nearly doubled between 2011 and 2020.
The numbers are shocking, but even more so when we look closely at the inequities inside the numbers. Black women experience the highest rates of severe maternal health complications.
Former Governor Charlie Baker created the Special Commission on Racial Inequities in Maternal Health to look into why those numbers persist, and committee members issued recommendations based on their findings.
But what’s actually happening on the ground? We know how bad it is, but what radical change is possible? Nashira Baril, founder and executive director of Neighborhood Birth Center, joined GBH’s All Things Considered host Arun Rath to discuss the role of midwifery in maternal healthcare and why she founded Boston’s first community birth center startup. What follows is a lightly edited transcript of their conversation.
Arun Rath: It’s kind of shocking—the state of maternal health care here in Massachusetts when we have so many of the best hospitals and cutting-edge healthcare—but let’s talk about solutions. You’ve advocated heavily for midwifery. Can you talk about the ways it can help remove these structural inequities?
Nashira Baril: Thank you for that question. The model of midwifery care treats pregnancy as natural and normal, not as a disease or something that requires high-level intervention, which is really different from the dominant kind of obstetrical model in our country.
Ninety-nine percent of people go to the hospital to give birth, which is really a shift from where we were just a century ago when the majority of people gave birth with midwives and in community settings at their or their midwife's home.
We’ve really moved into a highly medicalized model. In doing so, our healthcare across the board—not only in maternal and child health—is really driven by economics. In that drive and in that focus, we’ve really lost patient care, listening to people’s bodies and really trusting birth as a normal, natural physiologic process that often requires little to no intervention.
Rath: Those numbers that I mentioned at the beginning—one would expect this is really an all-hands-on-deck situation—but you’ve talked about state regulations on maternal centers that make it difficult to open a birth center. Explain that and talk about why these regulations have been an obstacle.
Baril: Yes, it’s true. Massachusetts has historically had really tight regulations on birth centers that, unfortunately, as I understand them, categorize birth centers as outpatient surgical units and require certain things from physician supervision to the level of lighting and washbasins that are usually limited to surgical settings. In coupling our birth centers with those regulations, it’s made a very restrictive environment for midwives and folks like myself committed to midwifery to open and sustain birth centers in this state.
The good news is that at the end of 2023, we got word that Governor Maura Healey and the Department of Public Health are looking at those regulations for the first time in years. We’re really excited about the opportunity to have midwives and birth center leaders in the room to have conversations about what regulations really support the midwifery model of care, ensure patient safety and protection, and also make sure that midwives can practice in the full scope of their work.
Rath: Obviously, hospitals make sense for high-risk pregnancies, but most pregnancies are not high-risk. At the same time—I’m shocked by this statistic—99% of births in Massachusetts happen in the hospital. How did we get to this level where that is just the norm?
Baril: I’ll offer you one more statistic as I answer the question: 85% of people—and this is a U.S. statistic, not just in Massachusetts, but I imagine it to be comparable here in the commonwealth—85% of people who do give birth in the hospital are considered low risk and could safely give birth outside of a hospital, in a community setting, either in a birth center or at home, as I did for both of my births.
How did we get here? I think, again, it’s an economic thing. There were policy and financial decisions made at the turn of the century that really moved childbirth out of the hands of midwives and community settings and into the hands of obstetricians. There was a rise of a medical model and this country actively divested midwifery. There were smear campaigns backed by the government to make community midwives look dirty and dangerous.
I think it really points to some historic policies and economic shifts in our health care system—the divested midwives. We are paying great consequences for that right now.
Rath: In terms of getting to a place where we’re not always going to the hospital, on your birth center’s website, you wrote about integrating lessons from other birth centers and from other social movements into the design of what would be a business model and clinical policies. Can you share some of those ideas?
Baril: Absolutely. I’ve spent the last ten years listening really intently to midwives and birth center leaders across the country as we were imagining a birth center here in Boston. I was listening for what was possible. How does it work? And from what I heard, it’s really hard.
The number one way that birth centers are financed in this country is by a midwife’s personal savings or her own lines of credit. I submit to you and the listeners that it’s just an absolutely unsustainable way to finance a really significant piece of our healthcare infrastructure.
Consequently, when that happens, the midwife is in debt and goes without salary for the first several years of operating. This is not uncommon. This is the majority of midwives I’ve talked to. The other consequence is that when they’re in debt, they’re less likely to be open to underpaying contracts from insurance companies, so they operate a cash-pay model. That certainly has impacts on who can access the birth center.
We double down on inequity—who has the capital to open up a birth center? We haven’t even talked about who gets access to the field of midwifery, which has been radically redlined. I’m a public health person by training, so I come to this with the lens of “How does it impact the populace? How do we scale it? How do we ensure that it’s sustainable?"
It really became clear that we need to create a birth center where midwives are thriving. A thriving midwife means a thriving community and thriving clients. In order to do that, we need to push policies to make the birth centers here in Massachusetts more sustainable.
Back to the question, “Are we ensuring that the midwives thrive?” Generally, midwives work 80 to 90 hours a week in a birth center and earn 50% of their hospital counterpart’s salary. So, we’ve said, “Not here. Not at Neighborhood Birth Center. Not in this wealthy commonwealth.” We have built into our business model a limit for their clinical hours. We’ve tried to make salaries on par with the large teaching hospitals in the city so that we’re not asking anyone to take a pay cut.
Again, we turn to philanthropy, but long-term sustainability means we need better contracts from payers and regulations that don’t end up costing us significant time and money.
Rath: You’re on the ground doing this work right now? You’re in that 1%?
Baril: We are! We’ve purchased property in Roxbury. It’s been a 40-year vision of midwives in the community to have a birth center in Boston, and in Roxbury in particular. I often think about the stories that can come out of the birth center, how we can have an impact, shifting the narrative and bringing more people to the safety, comfort and care of midwives.
I think about all of the births that will happen with comfort, peace and safety in a beautiful, home-like setting that we’re designing. There’s so much possibility when we invest in community midwifery, and I think there’s so much healing possible as well.
