Rhonda Okoth had visited her hospital twice about her water breaking, but no one listened.
The first time, Okoth was told that her water wasn't broken and that she should go home to do some exercises to rev up her contractions. The second time, still leaking fluid, Okoth was told that she had just urinated on herself and was sent home to spend the night in adult disposable underwear. Okoth, a Black woman, is a registered nurse.
The third time, medical staffers were alarmed because her amniotic sac had ruptured - she needed an induction and an emergency Caesarean section.
"I was like, 'Y'all didn't listen to me yesterday,' " she told The Washington Post in an interview. "By the time I got to the hospital, I wanted a more natural birth because now I'm receiving antibiotics and I'm hooked up [to machines]. [My baby] did not tolerate the induction because there was no fluid left around him. In between that, his heart rate was going down."
That experience - of her concerns being ignored and dismissed at a place where she wanted to feel safe - influenced her decision to have her next birth in the comfort of her home in July 2020, as the pandemic raged, with the help of a midwife team and doulas.
Okoth is among an increasing number of non-white birthing people who sought hospital alternatives for their labor and delivery as health for the birthing population among people of color lags behind that of white people, according to a new report released by the National Partnership for Women and Families (NPWF), a nonpartisan and nonprofit advocacy organization that works on public policies and education about women and families.
The report found that community births, which it defines as births at home or at community birthing centers, increased by 20 percent from 2019 to 2020 with upticks across racial and ethnic lines. Non-Hispanic Black women used birthing alternatives 30 percent more in that span, and Native American women 26 percent. The increase was also seen in Hispanic, Asian, and white women, who logged 24 percent, 18 percent, and 18 percent respectively, according to the report. Native Hawaiian or Pacific Islander women had a reported an increase of 13 percent.
The report also highlighted better results for healthy moms, which it said would be more likely to have vaginal births and less likely to have perineal tearing. As more pregnant people, especially people of color, learn how dangerous pregnancy, labor, and delivery can be, more are turning to options where they feel seen, heard and cared-for by people who are more likely to treat them with respect. Medical professionals and advocates of birthing alternatives told The Washington Post that the health system should be improved, and they noted that adding midwifery and doula services, with some caveats, could lead to improvements for birthing people.
Black women are three times more likely to die of a pregnancy-related cause than white women, according to the Centers for Disease Control and Prevention. The federal agency noted that variation in quality health care, chronic conditions, structural racism, and implicit bias contribute to that statistic. Native American/Alaskan Native women and Asian/Pacific Islander women also had higher rates of death in comparison to White women, according to the health agency. More than 800 women died of maternal causes in 2020, an increase from 754 in 2019, with Black and Hispanic women showing significant increases, according to a CDC report released this year.
For some in 2020, hospitals became scary places where people feared exposure to the coronavirus against a backdrop of a country struggling with its racist past, said Sinsi Hernández-Cancio, one of the co-authors of the report and the group's vice president for health initiatives.
"Now, more than ever, it's important to find ways to support these choices in many ways that could be lifesaving," she said. "Most birthing people can safely give birth in a birthing center or at home, but the availability is very limited."
Hernández-Cancio and partners of the report, including the American Association of Birth Centers and the American College of Nurse-Midwives, recommended two dozen policy considerations for federal and state policymakers that they say would make access to community birthing more accessible and reimbursement more widespread for those services.
"If insurance doesn't cover midwives or pay them so little that they can only take few patients or doulas can only have so many under their care," Hernández-Cancio said. " . . . The economic scaffolding around birthing is completely biased toward high-intervention birth."
She stressed that many birthing people need medical interventions such as surgery or medication, including her own emergency Caesarean, but she emphasized that there should be more than one path for safe labor and delivery that health systems don't support in many areas of the country.
Vanessa Barnabei, professor of obstetrics and gynecology at the University at Buffalo's Jacobs School of Medicine and Biomedical Sciences, said most of the findings of the NPWF were credible, and she agreed that integrating midwifery services into traditional practices can help patients, their babies and physicians.
Barnabei did, however, have concerns about the report’s claim that birth center infants were 26 percent less likely to be born preterm compared to those born in hospitals, a stat she called misleading.
"They shouldn't be doing deliveries of preterm births in nonhospital settings," she said. " . . . It's hard to figure out where they got that number and how it's relevant."
Barnabei said parents should meet with different providers. If they choose to give birth outside a hospital, they should make sure their provider has a backup plan in case something goes wrong.
"If you've already sacrificed nine months of your life taking care of this fetus inside of you, why would you take the risk of delivering at a home or birthing center?" she said. "Even though it's not needed that often, when it happens . . . it's just tragic to have invested all these months of your life. That just scares me. Obviously, I have a medical perspective."
Edward Hills, professor in the obstetrics and gynecology department at Meharry Medical College in Nashville, Tenn., said birthing centers, midwives, and doulas have a responsibility to screen out unhealthy potential patients, though he said he’s unsure whether their facilities have the medical capabilities to accomplish that.
Yet, he said, these services should be supported.
"The big deal now is that women should have reproductive justice and that they should reproductive rights and social justice," he said. "To me, justice means equal access to health care without race, poverty and income levels being considerations."
The sacrifice and associated risks of at-home births were never factors for Shanille Bowens, whose fifth pregnancy left her intimidated and unheard, she said.
"In my previous pregnancy, the doctor threatened to drop me from care because I preferred to not be catheterized, because it's very painful," she said. "I did push back, but I kind of was out of options. Not too many providers take you after a certain point. I felt kind of stuck with him. The only thing that was going through my head was: Never again."
Bowens, 38, wanted her sixth birthing experience to be more special.
She had a meeting with a Black nurse-midwife who had started her own practice. Bowens, who is Black, formed a relationship with her midwives and doula team, she said.
She said doctors saw her as a high-risk patient because of her previous miscarriages, but Bowens's fear of that label didn't deter her from choosing the care she wanted for the first birth she would have without her husband, who had died shortly before she found out that she was pregnant.
The day of her sixth child's birth in 2018, she woke up ready to do a maternity photo shoot, asked her eldest son to take a picture of her because she thought her baby could arrive that day, then went shopping for beauty supplies and fabric. That's when she felt contractions and texted her midwives just in case.
They told her they were on their way.
When she got back to her home, all five of her children and her birth team were present to help.
Bowens gave birth to her son on the couch in a bedroom as his older siblings looked on with tears of happiness and gratitude in their eyes.
“Even though my husband wasn’t there to see our son born, the children wouldn’t have been able to witness it if I was in the hospital,” she said. “It was an appreciation for their little brother. We call him ‘Little Blessing Baby.’”
Bowens's and Okoth's experiences with midwives were so helpful that they inspired them to become doulas.
Bowens, who is studying midwifery, credits the pandemic to her path in birth work, which her oldest daughter also wants to pursue.
“In certain ways, COVID came in and threw us off our feet, made us step into our purpose, and walk in that direction,” she said. “It really opened people’s eyes to what they’ve been missing and what was needed.”