2020-02-13
Story

Demetra Seriki, left, the only Black home-birth midwife in Colorado, with Lance and Debrisha Flagg and their newborn baby during an office visit. 

Photos by Joe Mahoney/Special to The Colorado Trust

By Kristin Jones

Babies were Dr. Justina Ford’s specialty.

Colorado’s first Black woman physician, the daughter of a former slave, received her license to practice medicine in the state in 1902. And though she was denied hospital admitting privileges for much of that time, she made good use of that license until her death in 1952.

A generation of Black and immigrant Coloradans were delivered by Ford. The recollections of some of them are tucked into the back of Justina Lorena Ford, M.D.: Colorado’s First Black Woman Doctor, a book Wallace Yvonne Tollette wrote for young adults.

In one of the interviews in that book, Juliana Torres, who was delivered by Ford in 1941, remembered the physician delivering her younger siblings in their house in what is now Denver’s Auraria campus:

“Dr. Ford would stay throughout the two days or four or however long it took. She would sleep on the couch. She had so much patience and was a real lady. She always wore dresses and an apron with pockets with her hair pulled back in a bun. Sometimes she came in a Yellow Cab. Her delivery fee was $15 or $20.”

Ford, who had trained in homeopathy at Hering Medical College, took what we might now call a holistic approach to care. Doris Ridge Todd, interviewed by Tollette in 2005, said that she considered Ford to be “a mid-wife and not a doctor partly because she always tended to our medical needs at our home.”

As a physician, Ford was a pioneer. In other important ways, though, she was the last of her kind.

In the years while Ford was practicing, the circumstances of birth were changing dramatically for most Americans. The kind of births that Ford ushered in at people’s homes—once common—became vanishingly rare. Births moved into hospitals, almost entirely.

But the benefits of the technological advances of medicine since Ford’s time never fully reached people of color.

Today, more than 98% of American births and 97% of births in Colorado take place in hospitals. And yet outcomes for mothers and babies are among the worst of any high-resource country. For African American and Indigenous families in particular, outcomes look more like they do in far poorer countries.

Pregnancy-related deaths among Black and Indigenous mothers in the U.S. are higher than among mothers in Tajikistan, where the per-capita annual gross domestic product is just north of $800. The African American infant mortality rate in this country is on par with Libya’s.

“The dirty little secret is that these people are dying in our hospitals, which should be our safest places,” said Monica McLemore, PhD, a University of California, San Francisco researcher into the intersection of maternity care and race.

The Centers for Disease Control and Prevention says there are steps that providers, hospitals, states, communities and families can take to prevent mothers from dying, from helping patients manage chronic conditions to making sure high-risk births happen at hospitals with specialized health care providers and equipment. Much of the practical focus across the country has been on improving practices in clinics and hospitals.

At the same time, some people of color in Colorado and elsewhere believe that hospitals are inherently dangerous for them—that outcomes would look better if more births took place in homes, the way they did for Ford’s patients.

Could they be right?

A spiritual heir

Today, there are more Black physicians working in Colorado than there were in Ford’s time—though not as many as you might hope, given that more than a century has passed since she began her work. Of more than 14,000 practicing physicians in Colorado today, the Colorado Black Health Collaborative can count only 91 who are Black. Of the state’s 253 medical school graduates in 2016, just three were Black, according to data from the American Association of Medical Colleges.

If you’re looking for a Black provider to deliver your baby, your options are slim. And if you’re looking for a Black person to do what Ford did—show up at your house, drink tea with your family, nap on the couch and catch your baby—there’s only one person like that in the state.

Behind a door in an unassuming office park in East Colorado Springs is a midwifery service called A Mother’s Choice. The service is run by Demetra Seriki, the only Black home-birth midwife in Colorado.

Seriki, whose clients call her Mimi, became interested in midwifery through her own experiences giving birth and attending the births of her friends. She’s convinced that the health care system is failing Black mothers, and wants to do better for the people who seek her out.

“If I knew then what I know now, I would not have had five children,” Seriki said. “Every time you walk into a hospital as a Black woman to give birth, you’re rolling the dice.”

Seriki educates her clients about their options for care—whether or not home birth is one of them. During their lengthy appointments, she helps identify early symptoms that could indicate risks, and guides people in getting the care they may need from dietary changes, supplements or a medical provider.

Seriki’s philosophy of care can be summed up in a few basic tenets, she said: “Treat Black people like humans. Shut your mouth for five minutes. Believe Black people when they say, ‘This is a problem.’”

Debrisha and Lance Flagg live in Pueblo, a 45-minute drive south of here. When Debrisha became pregnant with her first child in 2017, she found Seriki through a search for Black midwives.

“No one else could understand my lifestyle, the way I live, our concerns,” said Debrisha.

They also knew they wanted to do it at home, convinced that the hospital was unsafe. Lance was born in a hospital, and was injured by a doctor’s forceps. The nerve damage never healed.

Some forms of pain relief, like epidurals, are only available in hospitals. But Debrisha wasn’t afraid of the pain.

“I spent my whole pregnancy telling myself my body was made for this. And honestly, Mimi helped with that a lot, too. Every time we would come, she would be like, ‘It’s OK, this is natural,’” said Debrisha. “Black women have been doing midwifery for years, centuries. So I wasn’t too worried about it. I knew I would be in good hands.”

In the end, Seriki couldn’t be there for the birth; she was recovering from surgery. But her partner at A Mother’s Choice, Stephanie Sibert, attended the birth, and the Flaggs decided that if Seriki trusted her, then they would, too. Sibert ended up being a fine midwife, staying through the birth and even spending the night afterward to make sure Debrisha was OK.

It hurt, sure. At first, Debrisha was walking around outside, talking and laughing. And then she wasn’t. The labor went on and on—the pressure of the baby’s head was terrible, and did she really only push for 15 minutes? It felt like an hour and a half.

But then baby Israel was born, and when Debrisha looked into her eyes, “I just melted.” The baby girl looked just like her father.

Two weeks later, Lance, glowing, showed off a video of his baby daughter sliding into a tub of water. In a relaxed visit with their two midwives, the Flaggs chatted about how Debrisha had been feeling since Israel was born, how breastfeeding was going, and how the baby was doing. Seriki held the baby, who stared up at her in quiet wonder.

The Flaggs wouldn’t change a thing about their child’s birth.

Midwifery old and new

Home birth was once the only kind of birth.

Beginning in the 1800s, physicians, most of them white and male, muscled into a territory once exclusively held by women—including Indigenous women, immigrants, and enslaved women like Ford’s mother.

The shrinking of midwifery is a story of “the American medical profession policing the boundary of their profession,” said Indra Lusero, a Denver-based lawyer and advocate for reproductive justice who has studied the history of midwifery in Colorado and nationwide.

Because obstetrics was a relatively new arena for physicians, many of these doctors were inexperienced. (Some were outright cruel. J. Marion Sims, MD, known as a pioneer in the field of gynecology, experimented on enslaved women, subjecting them to excruciating gynecological surgeries without anesthesia.)

Midwifery was sidelined and finally banned. In Colorado, midwives were made to apply for licenses for the first time in 1915, and prohibited from using the same drugs and tools as doctors used, according to research by sociologist Patricia Tjaden. By 1941, the Colorado legislature passed a law that stopped issuing new licenses to midwives, essentially making midwifery illegal.

At the same time, as the health care system was established and formalized in the United States, births moved overwhelmingly into hospitals. By 1935, about 37% of U.S. births happened in hospitals. By 1960, it was up to 97%.

In the early days of this transition, U.S. deaths in childbirth actually increased, claiming progressively more mothers’ lives until the 1930s. Women of color were nearly twice as likely to die as white women.

Sepsis was a leading cause of death. Hospitals were rife with infection. Irvine Loudon, a British physician and leading historian of maternal mortality in Europe and the U.S. until his death in 2015, described physicians’ approach to sterility during this period as casual.

“The evidence suggests that between 1870 and 1935, it was usually safest to be delivered at home by a well-trained midwife rather than in a hospital by a doctor,” Loudon’s research found. Such trends were similar across many developed countries during this time.

Midwives eventually won back the right to attend births in Colorado and the rest of the nation, but with important limitations.

In 1977, a state law was passed that allowed certified nurse-midwives—licensed nurses with additional training and certification—to practice under the supervision of a physician. Later that year, in Aspen, Linda Vieira became the first certified nurse-midwife to attend a birth in Colorado. The University of Colorado opened its midwifery practice the following year, and by the late 1980s, Medicaid was fully reimbursing births attended by certified nurse-midwives.

Home-birth midwives were another story; this practice remained illegal. In 1991, the Colorado Supreme Court heard the case of Jean Rosburg and Barbara Parker, two home-birth midwives who were charged with practicing midwifery without a license. The two argued that the law violated the privacy of pregnant women by interfering in their choice of childbirth method. They lost.

Nonetheless, in 1993, Colorado law was changed to allow home-birth midwifery.

The number of people who give birth at home remains small. In Colorado, just 1,040 babies were born at home in 2017—out of 64,382 total births—and 10% of those were unplanned home births.

Is it safe?

Within the medical community, there is considerable debate about whether what Seriki and other home-birth midwives do is safe.

There are very few randomized, controlled trials comparing planned home births and planned hospital births. One reason often cited is that people are reluctant to allow a researcher to decide where they should have their babies—they want to make that decision for themselves.

Noting these limitations, the American College of Obstetricians and Gynecologists has said that it believes hospitals and birth centers to be the safest settings for births.

While planned home births are associated with fewer interventions than hospital births, the organization said, they are also associated with double the risk of perinatal death (stillbirths and deaths in the first week of life) and triple the risk of seizures or serious neurological dysfunction among newborns.

Some of these differences fade outside of our borders. In countries where home births take place within “tightly regulated and integrated health care systems, attended by highly trained licensed midwives with ready access to consultation and safe, timely transport to hospitals,” outcomes look much better, the organization noted.

A recently published systematic review and meta-analyses in The Lancet, mostly incorporating large studies in places where midwifery is well-established (including Britain and the Netherlands), found no difference in infant mortality between planned home births and planned hospital births for low-risk pregnancies. (There’s no universal definition of “low-risk,” but conditions that may increase risks include medical issues like chronic hypertension, diabetes or heart disease, as well as being pregnant with multiples or a baby presenting feet-first. Most pregnancies are low-risk.)

Another systematic review for low-risk births in high-income countries found that mothers faced fewer risks of severe perineal trauma and hemorrhage in homes, compared with hospitals.

In fact, Britain’s national guidelines recommend that people with uncomplicated pregnancies give birth at home or in a birthing center, under the care of a midwife. British guidelines note that the rate of medical interventions is higher under the care of physicians in hospitals, while outcomes are comparable.

Still, the American College of Obstetricians and Gynecologists cautions against making decisions for a birth in the United States based on what works in other countries. Studies elsewhere “may not be generalizable to many birth settings in the United States where such integrated services are lacking,” the organization said.

Lack of integrated services

Even within the U.S., there are differences in how well home births are integrated within the medical system, based on midwives’ ease of access to physician consultations and hospitals, and their scope of practice.

Colorado ranks roughly in the middle of U.S. states in its integration of midwives as a whole, according to the Birth Place Lab, which compiles research related to maternity care. Nurse midwives—though sometimes sidelined in the health care system—have legal protection and are covered by most insurers in Colorado.

Home-birth midwives are not.

Seriki and Sibert are certified professional midwives, who are registered to attend births through a process of education, examination and apprenticeship. Seriki also has a bachelor’s degree in midwifery from the Midwives College of Utah. They aren’t required to have a nursing degree, and they don’t.

Colorado is not among the 11 states where Medicaid covers the services of certified professional midwives. Few private insurance companies will, either. One barrier for insurers is that home-birth midwives aren’t required to have (and often can’t afford the high rates for) liability insurance, said Melissa Sexton, president of the Colorado Midwives Association.

As a business imperative, many midwives market their services to clients who can afford to pay their fees. But Seriki and Sibert have taken an opposite approach, advertising on their website that they offer discounted services to families with Medicaid, Tricare (which cover civilian health benefits for military personnel and their families), and families who are uninsured or experiencing homelessness. And while parents who give birth at home in the United States are disproportionately white, most clients of A Mother’s Choice are people of color.

“When I committed to this work, I knew that white families were gifted the ability and the right to choice, whereas Black families were not,” said Seriki. “A home birth is a privilege. I wanted to afford my community the same opportunity.”

Neither Seriki nor Sibert are able to make a living doing this work. Seriki runs a billing company. Sibert delivers pizzas.

Along with the financial constraints, there are legal and practical limitations placed on the practice of home-birth midwifery—also called direct-entry midwifery. Home-birth midwives are barred from using some drugs or tools that are available to obstetricians, family physicians or nurse midwives, and can face barriers in accessing physicians and hospitals when necessary.

While some physicians and hospital staff have developed collaborative relationships with home-birth midwives, others regard what they do as dangerous, which can make it difficult to work together, said Sexton of the Colorado Midwives Association.

“There’s a hospital I won’t go back to,” said Sexton, who declined to elaborate.

Johnny Johnson, MD, is an obstetrician and gynecologist who spent much of his career delivering babies at Rose Medical Center. Johnson began partnering with home-birth midwives after meeting one while he was on-call at the hospital. The midwife had come in with a client whose labor had stalled at home. He was curious and asked the mother: Why did she want to deliver at home?

The answer made a lot of sense to him: The mother said that birth was a normal experience, but the hospital treated it as if it were pathological.

Johnson, who is African American and was born at home himself, started going to meetings of midwives, consulting with their patients, and working with them as back-up if things went wrong at home or they otherwise needed a hospital birth.

Calling himself a “frustrated midwife,” Johnson is critical of physicians who treat patients without seeming to care much about their goals or experiences—following guidelines and protocols instead of patients. He’s critical of the number of unnecessary cesarean sections that are performed, and of the bias shown by some of his fellow physicians against women of color, mothers who are overweight and LGBTQ families.

“I can see why some of those patients want to deliver at home,” said Johnson. The fact that more women are choosing home births doesn’t speak well of the hospital system, he said. “An African American woman who finds a good midwife, who is low-risk—home might be an ideal setting.”

And yet, Johnson said, his views make him an outlier among health care providers.

“The consensus [among physicians and nurses] is, ‘if you give birth at home, you are playing Russian roulette. You are putting yourself and your baby at risk, and it’s unfair that if something goes wrong, you come to me,’” said Johnson. Physicians and nurses are often “open in their resentment of people delivering at home,” he added.

Johnson, who is 70, continues to consult with midwives but is no longer delivering babies at Rose. Sexton said it’s been hard to find other physicians who think like Johnson does.

Colorado’s Department of Regulatory Agencies, which oversees home-birth midwives, has consistently argued that for reasons of safety and cost-efficiency, midwives should be given more scope of practice—not less.

For instance, in their most recent review of regulations governing home-birth midwifery in the state, in 2015, the department argued that midwives should be able to suture first- and second-degree perineal tears, which are very common in childbirth, and to administer local anesthesia.

At the time, regulators noted, home-birth midwives were required to demonstrate competence in these tasks, and yet weren’t permitted to perform them in Colorado. (The state legislature agreed, and this changed in 2016.)

“All the rules and regs,” said Sexton, “are what keeps us safe and our clients safe.”

Disrespect and abuse

Lusero, who uses they/them pronouns, gave birth at home, and found the experience to be transformative. They want the experience to be available to more people. And they believe that limitations on home births are putting new parents—and especially people of color—at risk by pushing them into hospitals.

The risks of hospitals, said Lusero, aren’t always measurable in mortality numbers or injury statistics. The risk is also of trauma—both to the parent and to the baby.

New parents swap stories about poor treatment in hospitals: a nurse who berated or neglected a mother in pain; a physician who performed an episiotomy—a surgical cut made in the perineum during childbirth—or C-section without adequate anesthesia or consent; a baby taken away immediately after birth without explanation. But researchers are only recently beginning to study it.

A groundbreaking 2010 analysis by the United States Agency for International Development found evidence for disrespect and abuse in hospital-based childbirth around the world. They found that women were being physically abused, coerced into interventions they didn’t want, discriminated against because of their race or ethnicity, scolded or abandoned.

In the United States, people of color face particular risks. A survey of 2,400 U.S. women found that roughly a fifth of Black and Hispanic mothers said they were treated poorly during their hospital stay because of their race, ethnicity, cultural background or language. Just over a third of Hispanic mothers surveyed found their maternity care provider to be “completely trustworthy,” compared with half of white mothers.

Another survey, of more than 2,000 mothers in the U.S. in 2019, found that 27% of women of color with low socio-economic status reported mistreatment (including loss of autonomy, being shouted at or threatened, or receiving no response to requests for help), compared with 19% of white women with comparable socio-economic status.

Poor treatment during childbirth can have durable consequences for mothers and babies. It has been linked to postpartum depression and post-traumatic stress disorder.

Given the degree to which people—and especially people of color—are experiencing trauma and mistreatment during childbirth, some researchers and advocates have begun to call these experiences by a new name: “obstetric violence.”

“Essentially, it’s this kind of disrespect and mistreatment in the perinatal period,” said Lusero. “There are gradations of it, in the same way there are with sexual harassment and sexual assault.” They said this kind of violence is the best argument that people who want home births should be able to access them.

There’s evidence that when people give birth at home, they’re more likely to be treated respectfully by their care providers. Nearly a third of women who gave birth in hospitals said they were mistreated, according to the same 2019 survey, compared with just one in 20 who gave birth at home.

Mistreatment of Indigenous women

Melissa Rose is an Akwesasne Mohawk woman who grew up in upstate New York and now lives in Santa Fe, New Mexico. Like many Indigenous women, she grew up feeling disconnected from many of the traditions of her elders, including those having to do with birth.

“Our tradition in our community is that we’ve always had midwives. I’d grown up knowing that there were midwives and there are traditional medicine people in our society,” said Rose. “I wasn’t able to access them through the medical system.”

Rose was a teenager when she had her first child, in a military hospital in Oklahoma.

“I was really consistently dismissed and disrespected,” said Rose. The medical staff refused to address her directly—because of her age, Rose thought. Her baby was whisked away after birth, with little explanation. “We were separated for four hours before I even got to see her for the first time.

“After that, I said I would never have a baby in the hospital ever again.”

With some of the worst maternal and infant mortality rates—and a history of neglect or mistreatment by the health care system—Indigenous women have particular reason to be distrustful of hospitals.

Along with the fear of mistreatment, there are also rituals and other culturally important practices that can be difficult or impossible in hospitals: practices like burning sacred herbs—tobacco, sage, sweetgrass or cedar—or inviting traditional medicine people in to sing and drum.

And yet there is not a widespread call within Colorado’s Indigenous communities for more home births.

“I haven’t heard of anybody who wanted to do a home birth,” said Shawmarie Tso, a Navajo woman who works at Shining Mountain Health & Wellness in the town of Ignacio, in Colorado’s Southern Ute Reservation. She has tried to spark interest in doula services within the reservation. (Doulas offer non-medical support and coaching during births.) “Most of the time, people are anxious and afraid of not having the care if they’re doing something outside of the norm.”

There are good reasons for being cautious. Among them: The U.S. government has an ongoing history of separating Indigenous children from their families. At the same time, traditional healers have been at once fetishized and penalized throughout U.S. history.

“If your medicine people and your traditional healers have been systematically murdered, arrested, and taken away… If it’s been three generations since you had a midwife in your community,” said Rose, “if your medicine people got arrested for serving you, you’re not going to go to them.”

A good birth

Rose, who worked alongside Seriki for a time in Colorado Springs, is part of a new movement of Indigenous women who are trying to change things. She now works as a home-birth midwife with Changing Woman Initiative, a center that serves the needs of Indigenous women in New Mexico.

There’s growing interest: “We’re here in Santa Fe and we’re getting calls to attend births on the Navajo Nation three and a half hours away,” Rose said.

And for the Indigenous women who do seek out home births, despite the barriers, the events take on a meaning that isn’t measured within medical scholarship. These births are sacred for the whole community, said Rose.

“The most rewarding thing has been sitting at the feet of these elder women who have been midwives, thanking us for bringing these traditions back to the territory, to re-establish the relationship to land, those bonds that were broken,” said Rose.

“It’s so powerful to be connected in this primary way. You’re doing the exact same thing your ancestors did. You’re seeing the same things they saw. You’re smelling what they smelled. To have it happen on the same territory where their blood is, where their bones are, means that you’ve completed a cycle—and the cycle’s not broken anymore.”

By the end of Justina Ford’s career, most physicians refused to go into homes anymore. Ford was no longer locked out of the medical profession, and delivered babies in several Denver hospitals. And yet she also continued the practice of taking cabs to people’s homes and staying as long as they needed her.

There was very little documentation of Ford during her lifetime, or apparent interest in her from the media. Just one interview survives in Denver library archives, a wide-ranging conversation in an article in Negro Digest near the end of her life. Among other topics was why Ford kept delivering babies in people’s homes, though the world had moved on.

“Yet here was a little one about to come onto the scene and someone had to bring it, so why not me!” said Ford.

Ford was a doctor, of course, but she was more than that: She was her mother's daughter. Though others derided the traditions of community care passed down through generations of Black, Indigenous and immigrant women, Ford did not. The surviving accounts of her life suggest that she integrated this expertise into her practice, even as she brought her medical training home. 

Perhaps it's time our health care system followed. 

Related story: Midwifery at a Crossroads in Colorado

Kristin Jones
Assistant Director of Communications
The Colorado Trust