Over three weeks in January, Community and Social Impact Intern Theresa Nelson will share updates about the Healthy Youth Development Strategic Partnership team’s work to close equity gaps in Birth Justice by partnering with community innovators, advocates, and health workers. Follow along to be sure you don’t miss an update. (The cover picture is her abuelo, her tía, and one of her family’s new babies.)

Part I: Birthing as Community Practice

Practically every year, my family welcomes a new baby. Sometimes, more than one. In my Mexican American family, my grandma has nine siblings and my grandpa ten. I have tías, tíos, primas and primos for days, and kinship goes beyond blood. Any elder of mine, whether I know exactly how we’re related or not, is tia y tio – aunt and uncle – or nina y nino – godparents. I have friends and relatives so close that they have lived in my home and I in theirs; we share parents, some who birthed us, some who didn’t. The adults in my family use words whose honor cannot be similarly expressed in English, comadre y compadre – literally “co-parents” – to describe relationships of such great importance to them and their children that they see their families as one. As a child, I understood celebrations and holidays as times where we would gather, we would saludarles a los tíos, and we would hold the new baby. As an adult, I am only beginning to understand the gift of these relationships and their role in the birth of healthy families.

My name is Theresa Nelson, and I work for the American Family Insurance Institute on a Strategic Partnerships team. Alongside my colleague, Kaila Pedersen, our charge is to invest in Healthy Youth Development. We work to advance whole family well-being and youth activism by resourcing movements that innovate towards liberatory models of health, wellness, belonging, and care. We focus especially on work led by youth, families, and community health workers with lived expertise in systems of interlocking oppressions. This year, our mission led us towards a focus on Birth Justice, one which invited me to contend with the varied experiences of pregnancy, birth, and parenting in my family, and to center the lived experiences of the families and communities – alike and different from mine – most-impacted by birth injustice across the United States.

What is Birth Justice?

Birth Justice is a framework born from the Reproductive Justice movement led by a Black feminist collective, Women of African Descent for Reproductive Justice, in 1994. Reproductive Justice is grounded in the idea that “every person has the human right to maintain personal bodily autonomy, to have children, to not have children, and to parent the children [they] have in safe and sustainable communities.”

Why is Birth Justice essential? The United States faces a worsening maternal and infant mortality and morbidity crisis. Racism is the driving cause of maternal mortality disparities, which disproportionately impacts Black families, Indigenous families, and families of color throughout the entire perinatal period: pregnancy, birth, and postpartum.

The realities of birth inequity in this country are harrowing, especially when we look at birth outcomes. Black birthing people are three to four times more likely than their white counterparts to die of pregnancy-related causes. They are twice as likely as their white counterparts to experience severe maternal morbidity: “unexpected outcomes of labor and delivery resulting in significant health consequences.” Black birthing people die at a rate 3.5 times higher than their white counterparts postpartum. Black infants die at higher rates than any other racial group, and breast and chest feeding uptake is lowest among Black infants and parents, driven by systemically inadequate lactation support and predatory practices from formula producers directed at Black parents.

Indigenous, Native American, Pacific Islander, and Alaskan Native birthing parents are also three to four times more likely to die of pregnancy- or childbirth-related complications than their white counterparts. Non-white Hispanic and Latine/Latinx communities—who are least likely to have health insurance—saw a large jump in the rate of maternal mortality and morbidity since the start of the COVID-19 pandemic. While national data often tell incomplete stories, these problems are even more pronounced in rural communities, in the U.S. South, and for birthing families living on low incomes.

But there is more to Birth Justice than just bettering the survival rates for birthing people and infants. Birth Justice activists and organizers seek to dismantle the structural and social oppressions—racism, sexism, poverty, carceral systems, ableism, cissexism, heterosexism, and more—that prevent all birthing people from being able to give birth the way they want and in the conditions that they want. They seek to create conditions such that all birthing people, their infants, their families, and their communities have holistic access to healthy, affirming, and culturally competent birthing experiences, free of interpersonal and systemic obstetric violence.

Birth Justice centers Black and Indigenous birthing people and birthing people of color; birthing people with low incomes; birthing people with disabilities; birthing people living in maternal care deserts; birthing people who are trans, nonbinary, and gender expansive; birthing people who are queer, lesbian, gay, or bisexual; birthing people who are undocumented; birthing people who are incarcerated; birthing people who are survivors of gendered violence. Birth Justice work supports not just the medical needs of birthing people, their infants, and their families in the perinatal period; it further combats the many interlocking oppressions impacting pregnancy, birthing, and postpartum outcomes and equity, all of which require dismantling.

The current perinatal ecosystem, poisoned by systemic oppression and rigged to fail many communities before their children are even born, is unacceptable. Birth Justice to us is a necessary investment in the autonomy and holistic wellness of birthing people, the health and development of our youngest community members, and the wellbeing of their families and systems of support. When part of our entwined network is hurting, it impacts us all.

The value of collective care taught to me in my family is central to a more just birthing future. Many organizers and activists working to dismantle and re-imagine these systems of birthing on large and small scales agree. My job on this Institute team is to continue to learn from them, to elevate their work, and to resource its advancement. What can these re-imaginations look like? One approach is the re-orientation towards birthing as a community practice. These visions are embodied by the work of community-based doulas.

Centering community care in birth

Community-based doulas are birth workers who come from the communities they serve, sharing the same “background culture and/or language with their clients” to provide “physical, emotional, and informational support” to birthing people and families through pregnancy, birth and postpartum. Community-based doulas make “additional home visits and [provide] a wider array of services and referrals for individuals who need more comprehensive support” compared to traditional doulas, and they are especially impactful in “ensuring that pregnant people who face the greatest risks have the added support they need.” They provide care at “low or no cost and [their work] is grounded in safe, dignified, and respectful access to health care,” many for the first 1,000 days, encompassing pregnancy, birth, and the first two years of a child’s life.

Not all doulas are the same. Community-based doulas differ from traditional or private-pay doulas, who provide support to and advocacy on behalf of their clients before, during, and shortly after birth. Private-pay doulas are primarily white, college-educated, married women with children; in other words, they are far from representative of the population of people most impacted by birth injustice. Their clients are primarily white, class-privileged women. Many who would benefit from the support of a doula – birthing people of color, low-income birthing people, and LGBTQ+ birthing people, for example – “remain unaware of the availability of doula services, are swayed by stereotypes about who deserves access to doula care, or are not in a financial position to afford to pay for a doula’s services during their pregnancy, birth, and postpartum journey.”

When a birthing person has the support of doula care, it increases rates of vaginal birth, decreases time in labor, lowers the number of preterm births and births of low-weight infants, decreases likelihood of birthing complications, reduces rates of postpartum depression and anxiety, and increases positive feelings about birth experiences. Community-based doulas – who can provide full-spectrum care beyond birth – produce benefits including and beyond what traditional doulas provide. Birthing people who work with community-based doulas:

• Have lower rates of cesarian section births,
• Increase breastfeeding and use breastfeeding exclusively for longer,
• Increase use of prenatal care,
• Increase maternal and pediatric postpartum visits,
• Receive connections to “resources for low-income families [which] can profoundly…[strengthen] health in the prenatal and early childhood periods, reduce chronic disease across the life course, and increase attachment, which is critical to social-emotional development and school readiness,”
• And receive “appropriately mediated communication with providers…[when experiencing] cultural or linguistic barriers.”

A national survey found that the people served by community-based doulas are some of the people facing the most barriers to quality, dignified care at the intersections of interlocking oppressions. Data from 2008-2012 found that clients served by community-based doulas:

• “[Were] low-income (86.66% WIC eligible),
• Had limited formal education,
• Faced other challenges that significantly impact birthing outcomes, [including experiencing] barriers accessing and utilizing services and support that they needed most, both medical and social,
• Were majority Black (33.1%) or Hispanic (47.1%) but also included a small percentage of American Indian (4.6 %) and White (5.2%),
• Most were young; two-thirds (66.21%) were younger than 25 years old.”

While more attention in the United States is paid to the worsening maternal and infant health crisis, much of it further marginalizes the most impacted people and communities, or it pushes solutions that are individual-oriented, failing to account for the interconnectedness of policies, environments, medical care, social determinants of health, and systemic oppressions and their impacts on birthing. Meanwhile, community-based doulas and other grassroots approaches to perinatal care shift power away from racist, sexist, ableist, and dismissive systems and back to birthing people, their families, and their networks of support.

I am in awe with the beauty of these ideas: that I am healthier – and so are my infant nieces and nephews and birthing cousins – when our loved ones and communities are. That the systems that impact the youngest members of my family are the same that touch the oldest.

Our 2022 Year In Review

For Kaila and me, 2022 was our first year investing in Healthy Youth Development as a Strategic Partnerships team. And we are thrilled and humbled to highlight our two Birth Justice partners. Both orchestrate community-based doula programs to close equity gaps in birth justice, and both advance a vision for affirming community and family care.

• HealthConnect One is a national leader in training community birth workers who serve as doulas and lactation consultants. They are an organization for Black, Brown, and Indigenous birthing families, and their work includes training, mobilizing, connecting, researching, and advocating on behalf of birth workers and birthing families.
• The Cihuapactli Collective is an organization serving the Indigenous diaspora in Phoenix and other parts of Arizona. Their Birth Equity and Reproductive Justice work includes a Community Birth Fund, Ancestral Womb Wellness gatherings, and training to support birth workers in sacred community practices. Their advancement of birth justice is inextricable from their work of cultural revitalization and education, food justice, and decolonized wellness.

Over the coming weeks, I invite you to engage with our “Babies, Aunties, Doulas: Our 2022 Birth Justice Year in Review” series to learn more about the work that our partners are leading and to elevate the vision for birth justice for all that we join them in supporting.