April 25th, 2024
A Life-Changing Experience
Cambridge, MA—Merline Sylvain-Williams recalled how she slowly rose, waded in the water, and stepped out of the tub, leaving her husband behind. She took in the soft music playing in the background, the room dimly lit with tealight candles, and breathed into the serene atmosphere. She walked to the bed and laid down, feeling her next contraction coming. She then gazed at her son and daughter looking on, before closing her eyes to be fully present in her body. In this room, she felt power welcoming her son; in this room that was not her home, she experienced something sacred.
“For me to have had that experience, it changed me completely," said Sylvain-Williams during an in-home interview. "There's been a shift that's happened ever since I gave birth at the birth center. I feel like there's nothing that I can't conquer, which then brought me on a journey to become a birth and postpartum doula.”
Sylvain-Williams, a Black woman who grew up in Cambridge, MA, is a working wife, and the mother of three children. She received prenatal care during her three pregnancies at the Cambridge Birth Center, but delivered her first two children in a hospital setting. She made a different decision with her last pregnancy. In 2014, her baby boy was born in a birth center.
A birth center is not a hospital but a freestanding healthcare facility. In a birth center, licensed midwives provide prenatal, childbirth, and postpartum care. The midwifery and wellness model approaches pregnancy and birth as a natural physiological process. The majority of pregnancies are considered low-risk and can safely be delivered in birth centers. Most babies are born in hospital settings, but birth centers show better birthing outcomes than hospitals, including reduced racial and ethnic disparities.
Black women in the U.S. disproportionately experience maternal mortality and childbirth complications compared to women of other racial and ethnic groups. For instance, Black women are at least three times more likely to die due to a pregnancy-related cause than White women in the U.S. This disparity against Black birthing women remains true in MA.
In MA, the Cambridge Birth Center—where Sylvain-Williams delivered her third child—closed in 2020. The North Shore Birth Center followed, closing in 2022. Today, there are around 400 freestanding birth centers in the U.S., but only one remains open in MA: the Seven Sisters Midwifery & Community Birth Center in Northampton.
The Plight for Equitable Birthing
“I am still incredibly grateful for my midwife for supporting me throughout the whole journey and empowering me [in] the whole experience [to] have that bodily integrity and autonomy,” Sylvain-Williams reflected. She noted that her two previous childbirth experiences in a hospital were starkly different.
U.S. midwives were historically Black, indigenous, and immigrant people, assisting childbirth in homes and in communities. Racism was used to discredit them out of their birthing practice starting in the late 18th century, as childbirth was medicalized. Midwifery was banned from MA in 1907 and legalized anew in 1977. And it has been a battle ever since to restore the dignity and just value of midwifery. Midwifery is still misunderstood and undervalued in MA. Midwives’ services do not get reimbursed by insurance at the same rate as doctors and obstetricians for delivering babies, making it difficult for midwives to sustain a private practice in MA.
Michele Helgeson, a Certified Nurse Midwife and Advocate, confided during a virtual interview about her experience running her own practice. In 1989, the practice opened its doors in a small community hospital in MA.
“We set it up like [a] birth center. We were doing maybe about 145 deliveries a year," Helgeson explained. "We were there for three and a half years, but we ran into challenges because [as] midwives, we’re not reimbursed the same as doctors for doing the exact same thing, like doing a vaginal delivery. . . so we didn’t have a big revenue stream."
Midwife Helgeson emphasized that the midwifery philosophy of care places the birthing person at the center of holistic care.
A series of MA hospitals, maternity units, and birth centers closing over the years also drove inequities in childbirth, especially for Black and indigenous communities. Pregnant people have to travel longer distances for services. They receive care from providers lacking the cultural competency to establish trust with minority patients and in facilities where they cannot have continuity of care. Hospitals rebranding their labor and delivery rooms as “birthing centers'' further confused matters. While childbirth in birth centers is empowering, it is often traumatic in hospitals where minority patients don’t feel heard.
In 2023, the Massachusetts Department of Public Health (DPH) reported that between 2011 and 2020, severe maternal morbidity (meaning severe injury and illness related to childbirth) has doubled, affecting non-Hispanic Black people the hardest of all racial and ethnic groups. Heart attacks, acute kidney failure, amniotic fluid embolism, eclampsia, sepsis, and life-saving procedures are among the unexpected complications experienced with childbirth. DPH makes plain that racism is at the root of the issue in their press release, and their report is a call to action for closing the racial gap in maternal health in MA. Helgeson spoke about the increased attention brought to the issue by the public and politicians.
“I can't believe that it took many decades to bring [racial disparities in maternal health] to the public's attention because we've known about this for a long time,” said Helgeson. “It's something that I think finally got risen to the attention of all of these people, including politicians.”
A Fight for Birthing Fairness
Together, midwifery advocates raised their voices regarding their status, and actively pursued pathways to course correct. They point to compelling evidence that participation in freestanding birth center care and midwife-assisted births lead to better experience and outcomes for birthing people.
"As a Black woman, knowing the statistics, it felt personal,” Sylvain-Williams expressed after the Cambridge Birth Center closed. “And I am optimistic at the same time, because I am also part of this group that is working together with Cambridge Health Alliance to basically add a little pressure to [re]open the birth center sooner rather than later.”
She and her son also joined the rally to prevent the North Shore Birth Center from closing. Her son proudly held the sign “I am a birth center baby!”
The Boston Globe covered the fight against the closing of the North Shore Birth Center in 2022. Midwife Helgeson is one of nine core members of the coalition leading many efforts to save the North Shore Birth Center. They organized the rally that Sylvain-Williams attended with her son. Before he became a MA State Representative, Manny Cruz also attended that rally. He took the closing of the North Shore Birth Center personally because his daughter was born there. Alongside other patients, they opposed this closing in a YouTube video. Despite all these efforts, the North Shore Birth Center closed. Cruz was deprived from this option for the birth of his son, but remained in the fight for birth centers through legislation as he became a representative for Salem, MA.
Emily Anesta (left) is co-founder of the Bay State Birth Coalition and has partnered with key members of the MA State House to impact change. One of her allies is Representative Kay Khan of Newton (right), a nurse who has spent the past 29 years in office advocating for women’s health. Representative Khan is leading a legislative push to pass game-changing laws for birthing people. In the MA State House, the two women sat side by side in Representative Khan’s office. Like accomplices, they reminisced on the maternal health battles that they have faced and spoke of the incremental changes that they have impacted over the years.
Anesta and Rep Khan meeting in the State House. Photo by Lauren Fox.
“I think that there's a lot more attention to maternal health than there has been for years and years,” Representative Khan recognized. “It has risen to the top. I am excited to report that the Attorney General here in Massachusetts has hired a person to service or pay attention to reproductive health.” Anesta added that “Governor Healy has directed the Department of Public Health to revamp [outdated birth center] regulations, and we're hoping to see some improvement there.”
And the Birth Lantern Flicks On
MA Legislative Solutions
“I think that there's a lot more attention to maternal health than there has been for years and years, it has risen to the top."
- Representative Kay Khan
“I was successful in passing legislation that developed a commission to take a look at why Black and Brown women are having more difficulty during pregnancy and delivery than White women,” Representative Khan explained. “That legislation passed in 2021, and the commission was formed [to] come out with a report.” That 2022 report provided a policy blueprint to address racial disparities in maternal health. The following year, the 2023 DPH report sounded the alarm on severe maternal morbidity faced in disproportion by Black birthing people in MA.
In the MA State House, there is a shared sentiment that enough limelight has been shed and support garnered legislatively for key bills to be passed in the 2023-2024 session. Shareholders are on the verge of winning a legislative battle to improve childbirth experiences and outcomes in MA. Representative Khan filed this bill (Bill H.2209/S.1457) with other members of the State House to promote access to midwifery care and out-of-hospital birth options.
Two caucuses talked about their critical support and engagement for the birthing bills. The 62-member strong MA Caucus of Women Legislators comprises all women legislators of both the House and the Senate. This means that nearly a third of MA legislature has endorsed these bills for maternal health this session. In the past few years, this caucus has also done critical work to successfully get a line item for birth center funding added to the state budget. In 2022, there was $100,000 in the state budget for the soon-to-open Neighborhood Birth Center. And in 2023, that line item amount was increased to a million dollars to open new birth centers in the state.
Executive Director of the MA Caucus of Women Legislators Nora Bent explained the importance of their caucus reach. “We work beyond just legislation,” Bent explained. “There is a funding question, there is the broad education awareness question, so we try to be present in all those spaces to see that it’s not just about maternal health, it’s about the entire healthcare system and how we show up in that space. So the budget is a good example of that intersectional work in the process.”
The MA Black and Latino Caucus is also actively supporting the bill for better access to maternal care. Executive Director Závon Billups believes that these bills are in a position to be pushed into action. Billups has worked to write conditional letters of support, put on events to raise awareness, and talk to people in the community to make sure the maternal health bill addresses their needs.
“I hope that the people that need access to this care the most get it, and I hope that all of our bills pass," Billups said. "I know [these bills] are in a position where they can be pushed to the finish line, and I will be doing my part to make sure that happens..."
The Neighborhood Birth Center
The Roxbury neighborhood is the heart of the Black community in Boston. In Nubian Square, a walk on winding Kearsarge Ave reveals a tucked away site, cocooned between the Resurrection Lutheran Church and Boston Day and Evening Academy. This site, made of two old houses and an open lot, was purchased in 2023 to house the Neighborhood Birth Center.
Health Equity Strategist and Neighborhood Birth Center Executive Director Nashira Baril volunteered in the role for seven years, and came in a part-time paid capacity in the past three years. The decision to place the Neighborhood Birth Center in Roxbury was a strategic and geopolitical choice, made to meet the inequity for the Black community.
Archaic state regulations tied to surgical units require building the Neighborhood Birth Center from the ground up instead of renovating existing infrastructure. If passed this legislative session, Bill H.3616/S.1335 will update these regulations. Work is underway for the Neighborhood Birth Center to open in 2025.
“I feel like I have been a real student of birth centers for the last 10 years, listening, visiting every birth center that I could, talking to every birth center owner or leader,” said Baril during an in-home interview.
“I feel like I have been a real student of birth centers for the last 10 years, listening, visiting every birth center that I could, talking to every birth center owner or leader."
- Nashira Baril, Health Equity Strategist and Neighborhood Birth Center Executive Director
Baril standing outside of her home in front of a "Breaking Boundaries in @ Birth" sign. Photo by Lauren Fox.
Once fully operational, the Neighborhood Birth Center anticipates to deliver 300 babies a year, a volume that hospitals can make in a matter of weeks. Baril is both hopeful and realistic about the role of the Neighborhood Birth Center in the larger fight for birthing equity.
Baril was bombarded with messages and inquiries from pregnant people seeking an alternative to overrun hospitals for safe childbirth during the COVID-19 pandemic.
“While we’re still not open, this attention that turned our way as a result of COVID and the ways that COVID also shone light on all of the racial inequities that we’ve all known across measures in public health and in maternal and child health opened up a portal… and really accelerated our work,” Baril said. “In a lot of ways, the portal also looks like this incredible alignment of leadership on the city and state level and congressional level…that is thrusting us forward.”
“...the ways that COVID also shone light on all of the racial inequities that we’ve all known across measures in public health and in maternal and child health opened up a portal… and really accelerated our work.”
- Nashira Baril, Health Equity Strategist and Neighborhood Birth Center Executive Director
Baril at her home proudly showcasing Black Lives Matter flags. Photo by Lauren Fox.
Baril wants you to imagine a little lamp, a birth lantern on a porch. That lamp flicks on, letting everyone in the neighborhood know that a child is born. It creates a buzz in the community, and you are a part of that—300 times in a year. And birthing people in hospitals start demanding to be heard and empowered as a result of that exposure.
Sylvain-Williams experienced what Baril describes. Accompanying a friend to give birth at the Cambridge Birth Center made her want the same experience after two hospital births. “I want to be able to have birth in a traditional way,” she confided. “I want unmedicated birth, and I want it in a space where I feel safe, where I feel supported, where I feel like I'm connected to people. I don't want to just be another patient with a medical ID number, I want to feel like, there's a relationship.”
Sylvain-Williams recalled her first prenatal visit. Her midwife was transparent with her about the importance of staying healthy to be able to deliver at the birth center, because the birth center is not a hospital. Sylvain-Williams looked forward to every prenatal visit because her midwife listened to her and shared a lot of information without using medical jargon.
“I understood, and I was able to make informed decisions,” Sylvain-Williams emphasized. “And if there's anything I didn't understand, [my midwife] made time for questions, and I really felt supported. I felt safe and secure. The more and more I kept going to my appointments, I was like, yeah, this is where I belong. This is where I want to bring my baby into the world.”
"I want unmedicated birth, and I want it in a space where I feel safe, where I feel supported, where I feel like I'm connected to people."
- Merline Sylvain-Williams
The existence of freestanding, midwife-assisted birth centers in MA will create a portal into this narrative shift in childbirth experiences and outcomes, including intergenerational healing for all birthing people beyond birth centers’ clientele. In their own words, shareholders engaged in this fight impart their dream to change the birthing inequity narrative in MA.