Despite notable improvements in maternal and child health outcomes globally over the last 30 years, such progress has been stunted in the United States,1,2 where a greater proportion of people die from pregnancy- and childbirth-related causes than in any other high-income country.2 In the United States, perinatal health improvements remain even more elusive for those in Black communities, which consistently experience the worst perinatal health outcomes3,4 compared with other communities. While every pregnancy is unique, the racialization of pregnancy for Black women* has long been one of the most reliable predictors of negative maternal and infant health outcomes in the United States. Racialization is the process of categorizing and marginalizing people according to race, which as a social construct depends fundamentally on the existence of social hegemony and serves to support structural inequity5 and structural racism. Black birthing persons and infants consistently experience mortality and morbidity rates double or triple those of White families for preterm birth, low or very low birth weight, and infant and maternal mortality.4,6,7 The situation is so dire that, in 2021, as part of the first national gender strategy in US history, the Biden-Harris Administration explicitly identified addressing the maternal mortality crisis in the United States, which has a disproportionate impact on Black and Native American women. This critical step in advancing the participation of women and girls in society called for landmark investments in care.8 In addition, the Centers for Disease Control and Prevention (CDC) finding that two-thirds of pregnancy-related deaths in the United States are preventable serves as both a tragic reminder that unequal outcomes are not inevitable and a call to immediate action.9
The American Association of Birth Centers (AABC) defines birth centers as freestanding home-like facilities in which prenatal, birth, and postpartum care is led by midwives.10 Birth Center Equity further defines community birth centers as freestanding home-like facilities that provide safe, culturally reverent, midwifery-led maternal healthcare for all.11 There is mounting evidence that birth centers offer a model that successfully supports the Triple Aim of healthcare: improving population health outcomes; enhancing patient satisfaction; and reducing healthcare costs.12,13 The Giving Voice to Mothers' survey of US birthing people documents experiences of mistreatment during childbirth in more than 17% of the more than 2000 survey respondents. In women with low socioeconomic status, 27.2% of women of color compared with 18.7% of White women reported negative experiences, demonstrating the impact of racism on care delivery.14 Factors contributing to the experience of higher rates of mistreatment included being a woman of color and when birth occurs in hospitals.14 Taken together, the opportunity to expand evidence-based approaches to maternity care and improve the care experience for Black, Indigenous, and people of color (BIPOC) birthing families requires new approaches to address health inequities.
The purpose of this article is to argue for urgency in moving forward a community organizing approach to birth center development led by Black birth advocates and rooted in equity values of safety, love, trust, and justice to address the abhorrent and ongoing inequities, structural racism, and health disparities experienced by communities of color. A description of the evolution of the Birth Detroit model of care is provided as an exemplar using a Black feminist standpoint that centers the voices of community in developing new approaches to maternity care that shift the balance of power to take urgent action to improve maternal-infant health and eliminate inequities in Black birthing communities.
BACKGROUND
Preterm birth and related factors create population health challenges to thriving and are a leading cause of morbidity and mortality among infants.15 Increasingly, research links toxic racism, poverty, and other social determinants of health to preterm birth.15 Such factors are especially salient in the environments of metropolitan communities such as Detroit. The Centers for Medicare & Medicaid Services (CMS) also found evidence to suggest that birth centers improved outcomes within populations covered by Medicaid health plans by addressing physical and social health concerns, from reducing preterm birth rates and low or very low birth weight to increasing breastfeeding initiation and ensuring patients feel respected by their healthcare team.16 These population health outcomes have both short- and longer-term implications for childbearing families.
The experience of care in birth centers across the pregnancy continuum has been shown to be more person-centered, promoting a higher level of engagement in care and trust in the providers of that care.17 In the AABC Strong Start program, Medicaid beneficiaries receiving prenatal care at birth center sites reported receiving respectful, accessible care and achieved high-quality outcomes from that care. People who birth at birth centers also report higher rates of positive experiences postpartum than those who birth elsewhere. Patients also reported psychological improvements, such as being better able to express themselves during birth, higher self-esteem postpartum, and higher satisfaction with their birthing experience.18
Birth centers are associated with reduced instances of mistreatment and racial disparities. A recent article on culturally centered care in birth centers examined the impact of care delivered at Roots, a Black-owned birth center in Minnesota, on client autonomy and respect. Elements of culturally centered care at Roots included valuing the client's cultural community as strength, racially concordant care when possible, upholding racial justice, and providing physically and emotionally safe care. Statistically higher levels of autonomy and respect were identified for clients regardless of race and affirmed giving birth in a birth center such as Roots is protective against experiences of discrimination. It suggests that community birth center care “confers benefit and may improve equity and the experience of BIPOC and families of color during the critical and transformative time of childbearing.”19 Yet, BIPOC-owned or -led birth centers make up less than 5% of the nearly 400 birth centers in the United States.20
Birth centers are a model of care that also offers a return on investment in patient-centeredness and cost value. The Center for Medicare and Medicaid Innovation (CMMI), a branch of CMS, recently reported that women who received prenatal care in birth centers had better birth outcomes, as well as lower costs, compared with similar Medicaid beneficiaries who birthed in another setting.21 These findings highlight the specific impacts on reduced rates of preterm birth, low birth weight, and cesarean deliveries. In addition, CMS found that births in birth centers save an average of more than $2000 per mother-infant pair through birth and the year postpartum.22 Savings per birth center birth alone, excluding infant and postnatal care, were estimated to be more than $1000 for Medicaid patients.22
Birth center ownership is also challenging. A 2015 survey of 151 birth centers in the United States revealed that 81% of birth center founders had existing practices prior to their openings, and 83% of responding birth centers were for-profit entities and 17% were nonprofit. For start-up costs to launch a birth center, 58% were opened using personal funds, 42% leveraged bank credit or mortgage, and 27% benefited from investment gifts from family and friends.23 These findings demonstrate that the model for founding birth centers is heavily reliant on access to inequitably distributed resources. Women of color–led efforts to establish community birth centers, from Colorado to California, Michigan, Mississippi, and Massachusetts, struggle for resources. Many birth workers and population health leaders of color are then working unpaid to establish nonprofit entities and raise the funds needed to open birth centers to address the grave birth outcomes they and their communities face.
Transforming the spirit of care requires the recognition that the very essence of birthing care is steeped in racialized and gendered oppression, as well as traditional power frames. Oppression is seen in the process of mother-blaming for health outcomes,24 positioning of obstetrics over midwifery despite compelling evidence advocating for normal physiologic birth over medicalized surgical birth, and a maternity care system steeped in structural racism,24 as well as within midwifery and birth center networks, where there are significant structural barriers to entry for people of color. New models of birth center development that address the historical and persistent inequities in birth outcomes, care options, and access to capital in communities of color are urgently needed. The Birth Detroit model is a new model to address these inequities.
BIRTH DETROIT MODEL
National inequities in perinatal health outcomes, access to birth centers, and midwifery care options for Black families are mirrored in the city of Detroit. This Michigan city is the largest majority-Black city in the United States, where the intersection of race and class exists against a backdrop of chronically underfunded public health services and health disparities.25 In 2019, 11% of infants born in Detroit were born to people who received either no prenatal care or late care beginning only in the third trimester26—a statistic nearly twice the US proportion of 6%. Infant health outcomes remain similarly alarming in Detroit. An examination of 3-year moving averages for infant mortality from 2008 to 2019 highlights health disparities, as Detroit's average Black infant death rate is 15.5 per 1000 live births—more than twice the White infant death rate of 5.8 per 1000 live births.27 While nationally, 12% of infants are born preterm and 8.3% are born with a low birth weight, these indicators are 17% and 14.8%, respectively, in Detroit.28
Birthing options in Detroit are currently limited to large health systems where births occur in labor and delivery units. Many birthing hospitals name their maternity units birth centers, although they do not meet the AABC definition of a birth center.29 There are currently 6 freestanding birth centers in the state of Michigan, but none in the city of Detroit. In addition, while hospital-based midwives in Detroit have had a significant influence at birthing hospitals since 1980,30 the potential of access to midwives and the known benefits of community-centered midwifery models are not yet realized.
In response to the intractable health and healthcare inequities and limited care options in Detroit, a team of community-based health activists and birth workers organized to expand access to midwifery-led maternity care services, including a freestanding birth center. The initiative, called Birth Detroit, seeks to change the narrative about birth options and expand approaches to maternity care services for the local community, while also serving as a model for other communities. Birth Detroit evolved from the realization that existing approaches to perinatal care have been insufficient in protecting Black birthing persons and infants across the city. Birth Detroit endeavors to expand the dialogue about community-driven care, Black-led service models, and community birth infrastructure as essential components in achieving maternal health equity in the United States.
Birth Detroit aims to realize the birth center model of care as a justice response to health inequity. By applying the justice principles of autonomy, opportunity, and accessibility, Birth Detroit challenges the prevailing idea of freestanding birth centers as a boutique model of care available to a relatively select few. Birth Detroit invites consideration of freestanding birth centers rooted in community as a care model that should be available to all birthing people as an essential population health strategy that has the potential to reduce health inequities.
As a Black-led organization shaped by community voices within its leadership ranks and its clients, Birth Detroit is dedicated to improving maternal and infant health outcomes within its communities. Since its inception, Birth Detroit has used evidence-based models as a foundation, tailoring its programs with reverence to the feedback from voices within its own community-based leadership and from the surrounding community. Examples of evidence-based approaches to care include midwifery-led care, offering childbirth education, doula support, home visits early postpartum, promotion of breastfeeding, and seamless transfers of care when necessary.
Birth Detroit's 4 core values are outlined in Figure 1. Models of care that seek to mitigate systemic racism, among other widespread systems of injustice, are often challenged to address oppression on either a micro level or a macro level. However, within the context of pregnancy and the birthing experience, healthcare providers have a rare opportunity to imagine interventions that can address individual family needs, while advancing policy changes that affect whole communities and creating systems that promote equity for future generations.
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Figure 1.: Birth Detroit values.
METHODS
Centering community
Following SQUIRE guidelines,31 the iterative process used to refine the Birth Detroit model, centering community, is described. Birth Detroit's founders and staff are predominantly Black women who have long-standing personal and professional ties to the community they serve. They perceived a demand for additional frameworks of care from the people they encountered daily. Furthermore, they envisioned a model that could be both for the community and by the community. In an effort to ensure this approach was followed, they considered stakeholder voices from a multitude of sources and carried out a series of key stakeholder interviews, community surveys, and outreach events between 2018 and 2019. The results of these activities are summarized in the following text and served as the foundation and guidance for the evolution of Birth Detroit.
Community stakeholder input
To examine the community's interest in a local birth center, Birth Detroit's founders launched a series of semistructured stakeholder interviews in 2018. Seventeen Detroit maternal-child health stakeholders representing 9 organizations and local birth midwifery activists were identified. The interview objectives were to gauge community interest, collect input about the types of services the interviewees believed would fill current gaps in care, and gather ideas to shape the founding values for Birth Detroit moving forward. Stakeholders were all well-known community leaders whose work sought to improve the health of mothers and infants in the city. The stakeholders were identified by members of the newly formed Board of Directors and via snowball sampling. Stakeholders categorized themselves into the following maternal and child health roles, while a few participants occupied multiple roles: 14 worked in administration; 3 worked in advocacy and policy; 9 worked as practitioners; and 1 worked in research.
The range of affiliated organizations included public health and publicly funded nonprofits at the local and state levels; local BIPOC midwifery and doula activist groups; a Black breastfeeding advocacy association; and 2 national organizations with a local presence. Stakeholders were asked questions about their perception of community need, necessary services to be offered, and ways in which the prospective organization could fill gaps in care associated with increased race-based maternal and infant health disparities.
Community assessment
As part of its planning and development, Birth Detroit distributed an online 26-question community survey from March 31 to September 19, 2019. The survey contained 23 multiple-choice questions: 6 about respondents' knowledge of midwives, doulas, and birth centers; 5 assessing their ideal provider and birthing experiences; 11 demographics; and 1 about past birth experiences. Three open-ended questions allowed respondents to share their feelings about their birth experiences and any additional information they wanted the organizers to know. Descriptive and bivariate analyses were conducted to assess the needs, desires, and experiences of the respondents related to perinatal care and birth experiences.
RESULTS
Stakeholder interviews
During the interviews, participants were asked to contribute to a strengths, weaknesses, opportunities, challenges (SWOC) analysis of the maternal care landscape in Detroit by responding to a series of questions (see Table 1). A summary of the outcomes of the interviews led to the identification of SWOC components (see Table 2). The desire for wraparound care was resounding, as the word comprehensive was mentioned in 13 of 17 interviews.
Table 1. -
Stakeholder questions for SWOC
a analysis
| Questions |
| What would you say are the strengths and weaknesses of the maternal health system in Detroit? |
| What services would you say a freestanding birth center should include? |
| How could Detroit health system(s) work in partnership with a freestanding birthing center? |
| What do you think partnership could/would look like? |
| What potential barriers and challenges would you foresee in opening a birth center in Detroit? |
| How do you think a freestanding birth center would impact Detroit families and maternal child health providers? |
aBirth Detroit opted to use the SWOC (Strengths, Weaknesses, Opportunities, Challenges) framing instead of the SWOT (Strengths, Weaknesses, Opportunities, Threats) because of the “T”s association with military strategy and the more positive framing of the “C,” as obstacles that can be overcome.
Table 2. -
SWOC analysis components
| Component |
Theme |
| Strengths |
Advancements in racial equity for breastfeeding |
| The unity of the community |
| A plethora of public and private agencies advancing maternal care |
| An increased number of providers of color |
| Weaknesses |
Lack of options for birth care funnels women into high-risk care |
| Systemic and institutional racism |
| Barriers to care, such as transportation |
| Lack of knowledge about the midwifery model of care |
| Lack of community representation among providers |
| Global billing |
| Opportunities |
Improve the geographic distribution of resources and transportation access |
| Enhance collaboration between organizations with similar missions |
| Expand education and awareness about midwifery models of care |
| Build a dedicated facility to address maternal healthcare, such as a birth center |
| Challenges |
Provider buy-in to the model |
| Perception of birth center as competitor rather than partner |
| Patients lack of ability to pay for care |
| Sustainable funding and payer models |
| Lack of community awareness about birth centers |
| Physical access concerns around transportation |
When asked about the impacts of a hypothetical birth center on existing Detroit maternal-child health providers, the answers provided a similar narrative. One participant lauded the “potential for closing some of the service gaps and having seamless referrals for families.” Similarly, one interviewee commented that with mortality rates rising, “[providers] need to try something else.” This was affirmed by a participant who observed that in the context of existing models not improving disparate health outcomes for birthing persons and children, innovative methods not yet offered to this community were a logical response. Another noted that “a lack of opportunities and options funnel women into care [that] is targeted for high-risk settings.”
Community survey
There were 391 respondents to the online survey, with 282 answering all questions. Results presented include both complete and incomplete surveys. One hundred fifty-four respondents (39%) were residents of Detroit. Of the Detroit population, 63% were Black and 25% were White. Of those outside Detroit, 49% were Black and 40% were White. The majority (83%) reported being heterosexual, and 10% identified as bisexual. Education levels were higher than the city of Detroit, with more than two-thirds having a college degree or greater. Income was also higher, with the median income being between $50 000 and $75 000 for both Detroit and non-Detroit residents.
The results of the survey indicated that nearly all respondents felt that midwives (98%), doulas (97%), and a birth center (98%) were a good idea for the Detroit community. More than half of Detroit residents surveyed said they would like to give birth in a birth center, and nearly one-third expressed they would like to give birth at home. Responses about prior birth experiences indicated that White residents were more likely than Black residents to have had a midwife provide prenatal care and to have had a midwife present at childbirth. Having a midwife was associated with greater satisfaction, more natural childbirth practices, and having a vaginal birth. These responses supported interest in access to accessible and affordable midwifery care to Detroit families. Furthermore, themes from content analysis indicated respondent desires for a provider who is trained in and follows standards of evidence-based practices and natural childbirth; is respectful of gender and sexual identity; treats the family with respect and dignity; and treats them/the birthing person as a partner in care, including respecting choices, boundaries, and body autonomy. To make the results of this process accessible to community members, an infographic (see Figure 2) that summarized the results was developed to serve as a point of accountability by Birth Detroit to address the needs and priorities the community stakeholders had identified. The survey concluded with an opportunity for respondents to answer an open-ended question (“Is there anything else you would like us to know?”), soliciting additional feedback not already captured by the survey. Exemplar quotes from responses to this open-ended question and supporting identified themes are provided in Figure 3.
Figure 2.: Birth Detroit community survey infographic.
Figure 3.: Exemplar quotes from survey themes.
Survey results were shared back to the community in a Community Launch and Learn event, which was an open house held on a Saturday with food, family welcome, and sharing of the Birth Detroit mission, vision, and goals. The event highlighted key findings and invited participant reflection, input, and questions about Birth Detroit. It also featured nationally recognized midwife Jennie Joseph as a keynote speaker on midwifery-led care as a solution to health inequities. More than 130 attended, including community birth workers, birthing families and children, civic and public health leaders, volunteers, and community supporters. The summary conclusion by the Birth Detroit founders was that this foundational stakeholder and community input supported the desire to gain momentum in moving the Birth Detroit vision, which was co-created with the community, forward.
Assessment outcomes
Cultivating community
The Birth Detroit founders and Board of Directors outlined priorities (see Table 3) in response to the results of the community survey and input sessions that centered community voice to build out the program planning process and cultivation of the Birth Detroit model. They employed a community organization approach to birth center development that commits to actively and authentically engaging communities as leaders in their own care. Community volunteers are essential parts of the Birth Detroit family, and there are 4 active volunteer work groups—each organized around one of Birth Detroit's 4 core strategies and working to uniquely support Birth Detroit: MIDWIFE, ADVOCATE, ENGAGE, and DEVELOP.
- MIDWIFE: Birth Detroit embraces midwife as a verb, meaning to bring into being. Birth Detroit was created to bring into being optimal maternal and infant health outcomes by making community-based midwifery care and a birth center birth experience available to all birthing people, regardless of ability to pay. The MIDWIFE work group supports Birth Detroit programs and services within the framework of bringing optimal maternal and infant health outcomes to all birthing people. Volunteers help with supplying and packaging perinatal supplies for families, providing stipend doula services to Birth Detroit families, and contributing to program and birth center planning.
- ENGAGE: ENGAGE supports Birth Detroit community engagement, marketing, and communications. Birth Detroit regularly issues a Birth Post newsletter, has produced 2 short videos highlighting services to the community, recently hosted an open house–style outdoor birthday party celebrating the first year of the Birth Detroit Care neighborhood midwifery clinic, and is working on a short documentary on the legacy and future of Black midwifery in Detroit.
- DEVELOP: Birth Detroit believes that as understanding of midwifery models of care grow, so will the resources to support the work. Birth Detroit commits to DEVELOP and steward relationships and resources well to fuel its mission. The DEVELOP team has grown a strong community of funders and individual donors committed to Birth Detroit's mission. The team exceeded its 2021 year-end fundraising goal with its Lead with Us campaign and is continuing to fundraise for the birth center to open in 2023.
- ADVOCATE: ADVOCATE works to address the lack of birth center licensure, reimbursement, and access in Michigan by collaborating with communities, community and birth justice organizations, and birth centers across the state to promote, resource, and advance birth center care in Michigan. In the last year, the ADVOCATE work group has developed a Birth Justice and Policy Agenda, and Birth Detroit led Michigan's successful application to the Institute for Medicaid Innovation's new 3-year national midwifery learning collaborative.32 The collaborative offers a rare opportunity for leaders from state Medicaid agencies, Medicaid health plans, midwifery practices, and community organizations to receive guidance and support on determining long-term solutions to integrating, implementing, and funding midwifery-led care in their states. Michigan joins state teams from California, Arizona, Kentucky, and Washington.32
Table 3. -
Birth Detroit priorities
| Priority |
Components |
| CENTER families and communities in perinatal care and birth center planning |
Be a model for community-centered Black, Indigenous, and people of color–led perinatal care and birth center development |
| Provide safe, quality, loving community-based midwifery care now (Birth Detroit Care) |
| Grow strong provider relationships and support Black midwives (current and aspiring) |
| Tell our story and document our journey, sharing the benefit to Detroit |
| GROW staff team capacity necessary to achieve our mission |
Fund our staff team at capacity necessary to achieve our mission |
| Nurture a strong, active, values-aligned, joyfully engaged Board of Directors |
| Develop values-aligned shared leadership model for Birth Detroit |
| OPEN model Black, Indigenous, and people of color–led community birth center |
Identify, fundraise for, and secure birth center location by year-end 2022 |
| Open Birth Detroit freestanding, accredited community birth center by year-end 2023 |
| SUSTAIN staffing, leadership, and resources to realize the vision of Birth Detroit |
Establish public and private reimbursement for birth center care in Michigan |
| Establish birth center licensing and/or accreditation in Michigan |
| Support sustained staff team capacity, leadership, and governance |
Iterative planning
While initial planning was focused on the opening of a birth center in Detroit, by centering and responding to community input, the Birth Detroit trajectory was adjusted. An unanticipated priority from the stakeholder interviews and community assessment survey results pointed to the need for community-based perinatal care and education while Birth Detroit continued to plan for the birth center. In October 2020, Birth Detroit partnered with Brilliant Detroit, a nonprofit organization dedicated to successful families, kids, and neighborhoods, and the Michigan Health Endowment Fund, the state's conversion foundation focusing on the health of Michigan residents, to open Birth Detroit Care. Birth Detroit Care is a midwifery Easy Access Clinic modeled after the JJ Way, a highly successful community-based model of healthcare delivery developed by Jennie Joseph (JJ),33 and is the only community-based, easy access midwifery care clinic in Detroit. This unique perinatal clinic provides essential prenatal and postnatal care and resources to birthing families right in their communities, including warm, personalized, respectful prenatal and postpartum visits; confirmation of pregnancy; prenatal screenings and laboratory test results; ultrasound services; labor preparation; childbirth education; and warm connections for other needed support. The clinic is staffed by certified nurse-midwives and certified professional/licensed midwives, a JJ Way Common Sense Childbirth Certified Perinatal Educator, and midwife assistants.
The values-centered spirit of care is the cornerstone of the care provided at Birth Detroit Care. Other practices of note include a complete needs assessment; provision of prenatal vitamins and postpartum supplies; access to select community doulas stipend by Birth Detroit; and a postpartum assessment offered in home within a day of birth. Birth Detroit Care's first-year performance goals included (1) the number of families served at Birth Detroit Care and the number of families receiving childbirth education; (2) becoming part of a comprehensive suite of services for families during the childbearing year; (3) developing a plan for third-party payments; and (4) providing education about the midwifery model of care to community stakeholders.
Since opening, Birth Detroit Care has cared for more than 121 families and had nearly 200 perinatal health visits and warm referrals. Thirty infants were born with local birth care providers under the prenatal and postpartum care of the Birth Detroit Care midwifery team in the first year of service. Ninety-three percent of births were full-term, and 100% of clients initiated breastfeeding. The Birth Detroit Care easy access clinic made community-based perinatal care accessible to all birthing people who wanted care, regardless of their ability to pay. The clinic exceeded its goal for the number of families served by 51%. Its clinical team aimed to serve 80 clients but stretched to meet increasing community demand to serve 121 clients and provide childbirth education to 100 parents. Birth Detroit is currently developing comprehensive evaluation metrics for use in the clinic and in the birth center.
DISCUSSION
Reimagining what is possible
SisterSong34 defines reproductive justice as the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities. Voices for Birth Justice35 defines birth justice as a movement that believes when birthing people recognize their innate power to make the best health decisions for themselves and their families during all stages of the pregnancy, birth, and the postbirth period, that power will have a transformational impact on their family and community. Recognizing that access to evidence-based options is critical to achieving reproductive and birth justice, Birth Detroit extends the definitions offered by SisterSong and Voices for Birth Justice to further clarify birth justice as the human right to a safe and respectful birth experience including bodily autonomy, power to make choices, and access to midwifery care.
Birth Detroit operationalizes a Black feminist standpoint36 by identifying, naming, and prioritizing challenges and leading the work to address them. From the Board of Directors to the cofounding team, Birth Detroit strives to embody its values of safety, love, trust, and justice and to honor that process matters just as much as ends. While traditional birth center planning may rely heavily upon an individual entrepreneur, Birth Detroit decidedly took an organizing approach—centering community, relationships, values-based processes, a bias toward action, community-defined success, and telling their own story. In addition to grant awards, the contributions of private donors demonstrate the breadth of community ownership and partnership.
By leading in their own care, Birth Detroit invites courageous questioning of not only inequity in birth outcomes but also the inequities deeply rooted in current maternal health systems and approaches. Birth Detroit commits to create and nurture a culture of solidarity, equity, belonging, and shared leadership with respect to all aspects of social and cultural identity and professional credentials. Birth Detroit believes that both the spirit of care and the spirit of leadership matter and aims to embody safety, love, trust, and justice in care and within the organization (see Figure 1). Birth Detroit believes that by centering Black birthing people in the redesign of care systems, it can create systems that work better for everyone and that when held with conscious awareness and love, the experience of birth can be a unifying catalyst in diverse communities. Achieving this vision requires examination, healing, and growing together beyond the structural racism that has harmed everyone. Birth Detroit aims to create spaces for deep honesty and vulnerability and to practice awareness of White supremacy and how it shows up in organizations—all with a commitment to name, heal, and develop liberatory structures and new ways of being. By uplifting and reclaiming Black-led midwifery care, Birth Detroit aims to ensure communities are healthier, stronger, and freer.
Transforming the spirit of care
The foundational philosophy of transforming the spirit of care makes way for people impacted directly and indirectly by birth inequities to be leaders in their own care. Birth Detroit was conceived with the recognition that the same structural factors at the root of inequities in birth outcomes are rooted in the broader systems of care.
In an effort to bring visibility to these often invisible factors, Birth Detroit pairs evidence-based models with a foundation composed of equal parts community energy, wisdom, determination, and innovation. Clear causes of maternal and infant mortality and morbidity are evident in Detroit, as are promising community-led solutions aimed at disrupting the inequitable trends. This contrasts with prior approaches to birth center care that had limited accessibility due to limits in acceptance of Medicaid and locations outside of communities of color. The AABC Strong Start program has demonstrated the value of providing accessible birth center care for Medicaid beneficiaries, including comprehensive approaches addressing both the physical and social values of combined care.13,17,37 The value of culturally centered care in the birth center setting is demonstrated by the outcomes of the Roots Birth Center in Minnesota, where outcomes were enhanced for all populations that were served at this site.19 Birth Detroit seeks to build on the strengths of the Strong Start and Roots programs, centering community and Black leadership to address Detroit's crisis in maternity care outcomes for birthing families.
Creating Detroit's first birth center in which the health needs of Black birthing persons and their children can be met is one of the most promising evidence-based methods to improve the safety of the birthing experience on physical, mental, and spiritual levels. While it is important to name the root causes of health inequities in birthing, it is even more important to uplift evidence-based, community-chosen solutions such as the JJ Way and Roots Birth Center model that stand to improve outcomes, grow community power, and enhance the culture of care.
In alignment with prior calls for nurses and physicians to engage with community-based strategies to address structural racism, implicit bias, and inequitable access within maternity care, Birth Detroit amplifies these approaches.24,38 The Birth Detroit model argues for Black-led innovation developing new models of care, with nurses and midwives being leaders in these areas. Evidence-based models of care such as Centering Pregnancy, the Roots Birth Center, and the JJ Way are exemplars of nurse- or midwifery-led models of care that center community voices. In the context of Birth Detroit, nurses have been part of the advocacy to encourage changes in legislation, reimbursement models, and birth center development. BIPOC perinatal nurse leadership should be supported to positively influence policy, practice, and population health changes necessary to address inequities in maternity care. The Birth Detroit model encourages engagement by community members with dual identities as nurses and midwives, as well as advocacy for a Birth Justice agenda from all involved in service to the BIPOC birthing community.
Limitations of this work are noted and include the use of online surveys requiring technology access that can serve as a barrier to respondents. To counter these risks, qualitative interviews and launch events were also held. Another challenge is that community organizing is a time-intensive approach. The capacity to effectively engage community volunteers while Birth Detroit was forming and before funding was available for staff challenged the momentum of the project at times. Inequitable access to capital necessitates Birth Detroit organizing as a nonprofit and requires competing with other equally worthy organizations for grants and resources Detroit's communities need to thrive. Given these challenges, the purpose of this article was to share Birth Detroit's approach to aid others who may have similar goals and desires to be leaders and change agents in their communities and to address health inequity using a community-informed birth center model of care similar to Birth Detroit.
CONCLUSION
“Never ask permission to save your own life,” advises GirlTrek, the largest public health nonprofit for Black women and girls in the United States.39 Birth Detroit is a demonstration of this advice in action and has adopted the mantra, “We are no longer asking permission to save our own lives.” Detroit's first Black-led birth center, Birth Detroit, is a model of deep equity and systems change, shaped by science and evidence, and positioned as a promising practice with strong potential to deconstruct inequities in birth outcomes.
References
1. Belluz J. We finally have a new US maternal mortality estimate. It's still terrible.
https://www.vox.com/2020/1/30/21113782/pregnancy-deaths-us-maternal-mortality-rate. Published 2020. Accessed October 29, 2021.
2. Declercq E, Zephyrin L. Maternal mortality in the United States: a primer.
https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer. Published 2020. Accessed November 9, 2021.
3. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2019;68(35):762–765.
4. Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. J Womens Health (Larchmt). 2021;30(2):230–235.
5. Smedley A, Smedley BD. Race as biology is fiction, racism as a social problem is real: anthropological and historical perspectives on the social construction of race. Am Psychol. 2005;60(1):16–26.
7. Chinn JJ, Martin IK, Redmond N. Health equity among Black women in the United States. J Womens Health (Larchmt). 2021;30(2):212–219.
8. The White House. Fact sheet: national strategy on gender equity and equality.
https://www.whitehouse.gov/briefing-room/statements-releases/2021/10/22/fact-sheet-national-strategy-on-gender-equity-and-equality. Published October 29, 2021. Accessed January 15, 2022.
9. Davis NL, Smoots AN, Goodman DA; Centers for Disease Control and Prevention. Pregnancy-related deaths: data from 14 U.S. Maternal Mortality Review Committees, 2008-2017.
https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/MMR-Data-Brief_2019-h.pdf. Accessed October 29, 2021.
10. American Association of Birth Centers. What is a birth center?
https://www.birthcenters.org/page/bce_what_is_a_bc. Accessed December 22, 2021.
11. Birth Center Equity. Home page.
https://birthcenterequity.org. Accessed November 10, 2021.
12. Ryan OR. Achieving the Triple Aim of accredited birth centers. J Obstet Gynecol Neonatal Nurs. 2015;44(suppl 1):S20.
13. Alliman J, Bauer K. Next steps for transforming maternity care: what Strong Start birth center outcomes tell us. J Midwifery Womens Health. 2020;65(4):462–465.
14. Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77.
15. Guzman M. Welcome to Detroit, where Black babies are at higher risk of death.
https://www.theguardian.com/us-news/2019/jan/31/detroit-black-infant-death-rate-health-hazard-deprivation. Published 2019. Accessed October 27, 2021.
16. Urban Institute. Strong Start for mothers and newborns evaluation: year 1 annual report.
https://innovation.cms.gov/Files/reports/strongstart-enhancedprenatal-yr1evalrpt.pdf. Published 2014. Accessed October 27, 2021.
17. Stapleton S, Wright J, Jolles DR. Improving the experience of care: results of the American Association of Birth Centers Strong Start Client Experience of Care Registry Pilot Program, 2015-2016. J Perinat Neonatal Nurs. 2020;34(1):27–37.
18. Alliman J, Phillippi JC. Maternal outcomes in birth centers: an integrative review of the literature. J Midwifery Womens Health. 2016;61(1):21–51.
19. Almanza JI, Karbeah J, Tessier KM, et al. The impact of culturally-centered care on peripartum experiences of autonomy and respect in community birth centers: a comparative study [published online ahead of print November 24, 2021]. Matern Child Health J. doi:10.1007/s10995-10021-03245-w.
21. Centers for Medicare & Medicaid Services. Strong Start for mothers and newborns: evaluation of full performance period (2018).
https://innovation.cms.gov/files/reports/strongstart-prenatal-fg-finalevalrpt.pdf. Published 2018. Accessed December 22, 2021.
22. Howell E, Palmer A, Benatar S, Garrett B. Potential Medicaid cost savings from maternity care based at a freestanding birth center. Medicare Medicaid Res Rev. 2014;4(3). doi:10.5600/mmrr.004.03.a06.
23. American Association of Birth Centers. History.
https://www.birthcenters.org/general/custom.asp?page=history. Accessed November 10, 2021.
24. Scott KA, Britton L, McLemore MR. The ethics of perinatal care for Black women: dismantling the structural racism in “Mother Blame” narratives. J Perinat Neonatal Nurs. 2019;33(2):108–115.
25. Barry-Jester AM. Detroit once tried to privatize public health. Now it's trying to rebuild.
https://www.npr.org/sections/health-shots/2021/08/06/1024933341/detroit-public-health-privatize-covid-bankruptcy?t=1636300827756. Published 2021. Accessed November 8, 2021.
26. March of Dimes Foundation. Late/no prenatal care: Detroit, 2009-2019.
https://www.marchofdimes.org/peristats/ViewSubtopic.aspx?reg=2622000&top=5&stop=25&lev=1&slev=5&obj=1. Published 2021. Accessed December 22, 2021.
27. WIN Network Detroit. Infant mortality.
https://www.winnetworkdetroit.org/about-us/infant-mortality. Accessed October 27, 2021.
28. The Annie E. Casey Foundation. Low birth-weight babies in Detroit.
https://datacenter.kidscount.org/data/tables/5425-low-birth-weight-babies?loc=1&loct=3#detailed/3/58/true/1729,37,871,870,573,869,36,868,867,133/any/11984,11985. Published 2021. Accessed October 27, 2021.
29. American Association of Birth Centers. Standards for birth centers.
https://cdn.ymaws.com/www.birthcenters.org/resource/resmgr/AABC-STANDARDS-RV2017.pdf. Published 2017. Accessed November 8, 2021.
30. Walker DS, Bieda J, Lewis M, Wery J. Nurse-midwifery practice at Hutzel Women's Hospital, Detroit, Michigan: a quarter century of success. Mich J Public Health. 2008;2(2):8–18.
31. Standards for QUality Improvement Reporting Excellence (SQUIRE). Revised standards for quality improvement reporting excellence: SQUIRE 2.0.
http://www.squire-statement.org/index.cfm?fuseaction=Page.ViewPage&PageID=471. Accessed January 18, 2022.
32. Institute for Medicaid Innovation. State teams announced for three-year national midwifery learning collaborative.
https://www.medicaidinnovation.org/news/item/state-teams-announced-for-three-year-national-midwifery-learning-collaborative. Published 2021. Accessed October 27, 2021.
33. Commonsense Childbirth. The JJ Way®—a patient-centered model of care.
https://commonsensechildbirth.org/jjway. Accessed October 28, 2021.
34. SisterSong. Reproductive justice.
https://www.sistersong.net/reproductive-justice. Accessed October 27, 2021.
35. Voices for Birth Justice. What is birth justice?
https://voicesforbirthjustice.org/birth-justice. Accessed October 27, 2021.
36. Combahee River Collective. The Combahee River Collective statement.
https://www.blackpast.org/african-american-history/combahee-river-collective-statement-1977. Published 1977. Accessed January 18, 2022.
37. Jolles DR, Langford R, Stapleton S, Cesario S, Koci A, Alliman J. Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014. Birth. 2017;44(4):298–305.
38. Julian Z, Robles D, Whetstone S, et al. Community-informed models of perinatal and reproductive health services provision: a justice-centered paradigm toward equity among Black birthing communities. Semin Perinatol. 2020;44(5):151267.
39. Dixon TM, Garrison V. GirlTrek.
https://www.girltrek.org/. Accessed October 28, 2021.
