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Replacing midwives with doctors? Not our brand of birth justice!

WHJI Statement on DHH/Medicaid Proposal on Birth Centers
January 29, 2015

Update: The comment period has been extended till end of day tomorrow, January 30, after which legislators will make a decision. So please continue to make your voice heard on this!  

Today, Louisiana legislators will review proposed regulations by the Department of Health and Hospitals (DHH) that could severely limit freestanding birth centers and the practice of midwifery in Louisiana.  As with most restrictions of holistic and women-centered health care, these limitations will disproportionately affect Black women, women of color, and poor women in our state.

The stated purpose of the DHH proposal is to extend Medicaid reimbursement to birth centers. While Medicaid reimbursement for birth centers is a measure we enthusiastically support, this legislation would also place severe restrictions on the types of birth centers covered and on who can practice within them. First, the proposal excludes Certified Professional Midwives (CPMs). If the measure passes as written, CPMs would not only be ineligible to receive Medicaid reimbursement for their work in birth centers, they would also be restricted from serving any Medicaid-eligible patients, even if the center or the patient were to cover the full cost. This restriction would exacerbate the barriers to access to birth services for Medicaid-eligible clients, in a context where access is already the worst in the country.  It would also place severe limitations on the practice of midwifery in our state by hampering professional access for CPMs, who are trained, certified practitioners with knowledge that is greatly of need to their communities.

Secondly, the proposal would require birth centers to hire physicians as medical directors. This is a highly detrimental measure for most free standing birth centers, as it is not considered medically necessary, physicians are reluctant to take on such a responsibility, and the cost often threatens the financial viability of the center.  In New Orleans, Birthmark Doula Collective has spent years intensively planning for the opening of New Orleans’ first freestanding birth center.  A number of community groups, birth organizations, and scores of families and community members have collaborated and put deep investment towards this effort.  The restrictions put forth in this proposal would now make it almost impossible for the birth center to open, further limiting access to respectful, woman-centered care.

Ultimately, the restrictions DHH is proposing would take an otherwise beneficial measure and turn it into something that will directly undermine the health and autonomy of low-income women of color in the state, in a multiplicity of ways. Most glaring, nearly 70% of births in Louisiana are Medicaid-eligible, meaning that the proposal would cut off access to CPMs for low-income women and families. Meanwhile, the need for the patient-centered type of holistic care that CPMs can provide is growing. We live in the state with the highest C-section rate in the country – six times higher than the rate determined as necessary by the World Health Organization. Much of this is related to the profit-orientation of the medical system we have today:  surgeries draw in cash, but also saddle women with longer recovery times, higher risks of infection, and a more challenging transition to motherhood.

As a state, we also suffer from some of the worst birth outcomes in the country. Louisiana ranks second in low birth weight and third in infant mortality. We also have a very high maternal mortality rate. Many of these statistics are far worse for Black women. African American women have a 2.5 times higher risk of delivering a baby that is low birth weight (or fewer than 32 weeks gestation). This is due to a combination of social factors reflecting historical and institutional racism and interpersonal racism in the medical context.  Recent research is even confirming what women of color have always felt – that growing up with a lifetime of racism actually has physiologic effects on our bodies, creating chronic levels of the stress hormone cortisol and impacting the fetal environment. Racism is embodied, and expressed in our health.

The autonomy and self-determination of Black women and other women of color in the birthing process is severely limited in the hospital setting, following a legacy of the policing of Black women’s reproductive choices and racist mistreatment by the medical establishment. Given this context, alternative birthing environments are all the more meaningful, representing one of the few options where women of color can expect they will be heard and their birthing choices respected.

Restricting the practice of midwifery would be another deep blow to our community.  Midwifery is a calling and a practice that has deep roots in the Southern United States; deep roots specifically among Black women. It involves knowledge of the most universal human act that has been cultivated and passed down from generation to generation, in many cases brought in the hearts, minds, and hands of African women who disseminated their knowledge while living under enslavement. For generations, community midwives guided mothers through the birthing process, when hospital care was actually off-limits to women of color. As the last century progressed, birth was increasingly medicalized and hospitals came to be seen as the optimal location for birthing, and for non-consensual medical education and training on the bodies of women of color. Midwifery, as a practice controlled not by white men or the scientific establishment, came to be seen as illegitimate and threatening. The practice has now undergone waves of restriction, policing, and criminalization by the medical establishment and by the US government – often in the name of public health.  The public health truth is, however, that midwives’ care results in better birth outcomes, more respectful care, and less unnecessary surgical intervention. This has even been shown repeatedly in published research.  But the idea of women – particularly Black women – retaining power over such a vital aspect of human life, and one that could potentially make more profit if controlled by the medical establishment, is simply too threatening for some.

The DHH measure, as proposed, will only serve to benefit birth centers that are already part of larger hospitals at the cost of real health and well-being for our communities.  We encourage all of our community to make your voice heard on this measure, demanding that birth centers receive Medicaid reimbursement but without these detrimental restrictions. Please spread the word, and check out the following actions you can take:

SUBMIT COMMENTS: Comments can be submitted via email to or by mail to: J. Ruth Kennedy, DHH Bureau of Health Services Financing, PO Box 91030, Baton Rouge, LA 70821-9030.  Make your voice heard!