Mar 28

Diversity Matters: What Are Our Challenges?

Diversity Matters photo for webpageThe midwifery workforce in the United States is not representative of the racial and ethnic diversity of the childbearing population.

Despite a long history of midwifery in the black community, black women currently represent less than 2% of the nation’s reported 15,000 midwives. Relatedly, black women and infants experience the worst birth outcomes of any racial-ethnic cohort in the United States.” Keisha Goode, PhD

The first two webinars in our “Equity, Race and Access to Midwifery” series focused our attention on the tragic disparities in maternal and infant outcomes, particularly among black families, the underlying physiologic effects of racism, and steps we can take to reduce disparities. This week Keisha Goode, PhD, and Nancy Anderson, MD, MPH, will discuss the barriers to attaining a representative midwifery profession and the positive impact that a truly representative midwifery workforce could have on health inequities. They report on their landmark research, designed to reveal the experiences of contemporary black midwives and students in midwifery education programs, practice settings, and professional associations. Their important findings and recommendations are a call to action for all midwives.

Keisha’s research is the first study to systematically investigate the experiences and perceptions of contemporary black midwives. Her dissertation, “Birthing, Blackness, and the Body: Black Midwives and Experiential Continuities of Institutional Racism” was completed in 2014 and includes a comprehensive examination of the history of midwifery, particularly among women of color and immigrants, and the long-lasting effects of racism, both as midwifery is generally perceived in the U.S. and within the profession as it has developed in recent decades. Keisha’s qualitative study, included both CPMs and CNMs, and was conducted via in-depth, semi-structured interviews that addressed these questions:

  • How do contemporary black midwives interpret the increasing medicalization and credentialism of midwifery and its impact on their work?
  • How do contemporary black midwives interpret the relatively high black maternal and infant mortality rate in the United States?
  • How do contemporary black midwives interpret the relatively low percentage of black midwives and black women’s underutilization of midwifery services in the United States?
  • How do black midwives perceive and experience national midwifery professional organizations?
  • How do contemporary black midwives understand their role, its possibilities and challenges, in addressing issues of cost, quality and access in the current health care crisis?
  • What are the differences in black midwives’ experiences and perceptions by age cohort, years of experience and type of midwife, i.e. CNM, CM or CPM?

Keisha’s findings have profound implications for midwifery educators and association leaders, for preceptors and midwifery practices, and for those who advocate expansion of the profession.

“To the larger midwifery community, listen to your midwives of color. The future of midwifery and positively impacting birth and birthing options for all women in this country depends on it.” Keisha Goode, PhD

The second speaker in this webinar, Nancy Anderson will share her research project/needs assessment that aimed to understand the barriers that women of color experience with respect to the midwifery profession. Sponsored by NACPM, the objectives of her study were:

  • Understand the role of unmet financial need as a barrier to women of color who wish to enter the midwifery profession
  • Determine the ideal scholarship structure for financial aid to women of color who enter midwifery education
  • Learn more about other barriers to successful midwifery education and practice for women of color.

A few highlights from Nancy’s findings:
The study identified several areas of resiliency and strength that were important to the success of women of color entering midwifery. These included previous work experience and expertise; community support and engagement; and sheer determination. Nancy also found that, while a variety of learning options could meet individual learning styles and personal needs best, the plethora of educational possibilities, each with differing financial implications and a variety of regulatory consequences, also highlights the importance of an organized outreach and information program for potentially interested women of color.

The importance of adequate financial resources for education is difficult to overemphasize, particularly in a population of potential midwives who may be more likely to be lower income at the onset of their midwifery education. One particular complexity is that midwifery education requires tuition, room/board and books, just as other higher education, but midwifery education also requires financial resources for travel to preceptor sites, steady supplies of gasoline and reliable transportation for births, and possible payment for the preceptors. Participants universally described a number of daunting financial challenges both at entry and during the course of their midwifery education.

By definition, someone who is an ethnic minority differs in a culturally prescribed way from most of her classmates. In the best of circumstances, these differences can be daunting. In addition to coping with cultural dissonance, women of color enter any midwifery educational pathway as experienced survivors of racism from childhood, previous education, and/or their employment experiences. Previous educational exposure may have occurred within institutions that were systematically deprived of adequate resources. Students of color carry this reality on their shoulders when they begin their midwifery education. Given the load that they carry, these students need systematic support from educational institutions.

Cultural dissonance, isolation, and racism can reach a zenith during clinical preceptor rotations when students may have to travel, dislocating to isolated locations with few people of color. Given the threats to the academic survival, both in classroom settings and during preceptorships, support in the form of mentorship becomes a key resource. It is the emotional equivalent of a life raft for midwifery students of color in midwifery.

Given the multidimensional needs described, it is recommended that financial and other support needs be integrated into a “package deal” that includes elements of social support, peer support and mentoring.

In her webinar presentation, Nancy will describe her specific recommendations and how they might be acted upon by midwifery education programs, educators, preceptors, and those who could mentor midwives of color.

Two other factors, occasionally forgotten in our concern for inequity, should also be important catalysts for targeted workforce development. First, the US overall is changing in ethnic distribution. As of 2012 there are already almost equal numbers of white and ethnic minority children in kindergarten. It is anticipated that by 2050 white Americans will be an ethnic minority in the United States. A health workforce that does not adequately represent the population it serves will never be able to anticipate or respond to their needs.

“The bottom line is that midwifery will need a more representative (as opposed to diverse) professional workforce to survive. While there’s good evidence that the model of care associated with midwifery can make a difference in the lives of women and babies, midwifery is a client demand-driven profession….no one has to choose a midwife and there’s no reason that they should unless they see themselves reflected in the profession.” Nancy Anderson, MD, MPH

Find all March and April webinar offerings in this week’s newsletter