Access to Community Based Care

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Access to Community-Based Care

Many groups expressed the importance of having a care provider from within one’s own culture and community. It was important that their care provider understood their lived experience and concerns and was able to provide care that was realistic and relevant to their culture and values. They described searching for this type of care and finding it under the care of midwives or at a community birth. They appreciated access to prenatal, birth and postpartum care within their community. Some described finding a provider who shared their identity, culture, race, or heritage, and feeling respected and heard.

Key Findings

"The best thing was that my midwife came to my home for all of my visits and never had to do a vaginal exam."

Self-identified as Black, had a planned homebirth

"My midwife and the midwife she worked with were so respectful and informed that I trusted them to make the best decisions for me, if needed. They gave me a profound sense of being supported, competent and valued. Their knowledge of nutrition and herbal remedies was profound. I felt so lucky to have their support."

Self-identified as East Asian, gave birth at a freestanding birth center

"Being in the comfort of my own home. Feeling no pressure from anyone to do anything I wasn't comfortable with. I even got to play my piano through some of my toughest contractions as a distraction. Where else would have I been able to do that?!"

Self-identified as Puerto Rican, had a planned community birth

"The best thing was that my midwife came to my home for all of my visits and never had to do a vaginal exam."

Self-identified as Black, had a planned homebirth

Self-identified as East Asian, gave birth at a freestanding birth center

Self-identified as Puerto Rican, had a planned community birth

Of the women who said it was important to them to find a health care provider from their heritage, race, ethnic or cultural background, 69.0% of Black women, 3.7% of White women, and 49.1% of Latina women had difficulty locating a doctor or midwife from their heritage, race, or cultural background.

When asked about how often they worried about being treated unfairly because of race, heritage or ethnic group, almost all Black (96.4%) and Asian (95.7%) respondents said sometimes, often or always. This was also reported by 78.5% of Hispanic, 68.1% of Indigenous and 30.8% of White respondents.

“Finding a midwife or doctor who shared my heritage, race, ethnic or cultural background was….,” stratified by race.

What was the worst thing about your care?

"Racism, judgement, treatment because I was on Medicaid."

Self-identified as Black, had a pregnancy loss

"Best thing: (On planned home birth) It was tailored to our needs. Worst thing: The erasure of my queer identity in pregnancy."

Self-identified as African American, had a planned homebirth

What was the worst thing about your care?

"Racism, judgement, treatment because I was on Medicaid."

Self-identified as Black, had a pregnancy loss

"Best thing: (On planned home birth) It was tailored to our needs. Worst thing: The erasure of my queer identity in pregnancy."

Self-identified as African American, had a planned homebirth

Immediate family and friends were most often listed as sources of support when problems arise, followed by extended family and the faith community.

Less than 12% of respondents said that their health care providers helped them thrive.

The most vulnerable to disrespectful treatment by care providers were Indigenous women and women with social risks.

Who do we rely on to survive and thrive?

When deciding where to give birth, 98% of people who planned to give birth at home or in a birth center, said it was important for them to have control over their childbirth experience.

The same number said they wanted a peaceful, comfortable environment. Here are the most important factors that led to the decision to have a community birth.

Factors that were important in decision-making for a planned home or birth-center birth. Proportions are rank-ordered.

Self-determination and freedom from pressure was the most common theme from the narrative comments of those who planned home birth.

What was the best thing about your care?

"I was in complete control of choosing the options I wanted, and could fully trust that my midwife would refer me to a doctor or hospital for care if it became medically necessary. Because of this, I was able to completely relax during my labor and focus my entire energy and awareness on giving birth to my baby."

Self-identified as White, had a planned homebirth

"No interference from strange doctors and nurses coming in my room. Everyone that was involved in my labor and delivery was someone I have known for a while. I had freedom to move around freedom to eat and drink, I was able to labor how I wanted to. My baby was never taken away from me. I was able to bond with her instantly. I was able to have my first breastfeeding experience with her in my own bed."

Self-identified as White, had a planned homebirth

Many women wanted to see more midwives and doulas of color.

"Midwife of color who treated us with dignity, respect, and genuine care. Friends and mentors who did the same which aided me in the journey and making the right decision for me and my family. The community of people I had surround me was amazing, we all deserve that."

Self-identified as White, had a planned homebirth

People described self-identified, personalized, evidence-based, and vigilant care provided by midwives.

What was the best thing about your care?

"The care was based in evidence, I never felt guilty or pushed into anything I didn't want, and my midwife understood what I wanted and needed from this birth. She understood that I would have a very difficult time getting an honest chance at a VBAC in a hospital and that I was terrified of having another cesarean. I felt emotionally and mentally supported as well as physically."

Self-identified as East Asian, had a planned homebirth

"The midwife drew blood in her office instead of having to go to a lab where I always pass out on the floor and nobody cares. I also was able to refuse the ridiculous amount of testing I would have gotten if I had stayed at the regular clinic for poor people where I usually went for health care. I did go to them first and when I saw the amount of tests and intervention they wanted to do to me I left and found a midwife."

Self-identified as Southeast Asian, had a planned homebirth

"My midwife knows our family and she cares about us. She was in our home with us and we were always comfortable and cared for. My baby had a double nuchal cord and shoulder dystocia, so she had to cut the cord early and I had to really push to get him out. He wasn't breathing for about a minute. I knew throughout that very LONG couple minutes that she was taking the best care of us and that her 30 years of experience would serve us well. She was calm and collected, but determined and careful."

Self-identified as White, had a planned homebirth

Self-determination and freedom from pressure was a common theme of the large number narrative comments from those who planned home birth:

What was the best thing about your care?

Self-identified as White, had a planned homebirth

Many women wanted to see more midwives and doulas of color.

Self-identified as White, had a planned homebirth

People described self-identified, personalized, evidence-based, and vigilant care provided by midwives.

What was the best thing about your care?

Self-identified as East Asian, had a planned homebirth

Self-identified as Southeast Asian, had a planned homebirth

Self-identified as White, had a planned homebirth

Preferences for place of birth for a future pregnancy varied by race.

Preferences for hospital birth were slightly higher for Asian women and demand for home birth was especially high for Indigenous women, with over 70% of respondents stating that in future birth they would definitely want an “at home birth.” Black women reported high interest and least access to community birth.

Interest in birthing at home in a future pregnancy, stratified by race

The majority of women who planned a community birth (82%) felt judged or criticized for their choice of birth place. They reported that they were judged or criticized by the public, healthcare providers or hospital staff, their friends, their in-laws, their parents or work colleagues.

I felt judged or criticized about where I chose to give birth by______ stratified by planned place of birth (n=2138)

What was the worst thing about your care?

"The worst thing was that I had to fight my insurance company to pay for my out of hospital birth. Thankfully my husband is an attorney and forced the insurance company to cover our birth. Not everyone would have had the resources to fight them and that's a shame."

Self-identified as White, gave birth in a free-standing birth center with an OB in New York

"The first 4 months of my pregnancy, I was under the care of an OBGYN. I was still researching my options, so I missed out on 4 months care through my midwife. Once I told my OB about my decision, I felt very disrespected by him. Other than that, the worst was having to say goodbye to my midwives after it was all over."

Self-identified as White, had a planned homebirth

What was the best thing about your care?

"Doula support at the birth in a calm, safe, and desired birthing center where my experience was honored."

Self-identified as Black, gave birth at home (unplanned accidental or enroute)

"My midwives were caring and passionate in their work. They respected my birth plan and always had the time to talk to us at great length during prenatal visits."

Self-identified as Asian, had a planned homebirth

"My midwife is amazing. She was hard to find because there are not many midwives in this area. She actually drove 2 hours over a mountain pass (one way) for all visits and for the birth."

Self-identified as Black Caribbean, had a planned homebirth

"The midwife who was on duty the night I went into labor. She left me and my husband and doula alone in the bathroom/shower and let my labor progress naturally without intervention."

Self-identified as African American, had a planned hospital birth

"Everything! But postpartum in particular, my midwife helped me tremendously through a very difficult breastfeeding beginning, including a tongue and lip revision at 5 days old. My guilt weighed heavily but she just kept validating my feelings and encouraging me that it would get better and that I was doing great. Things finally got better 6 weeks postpartum, and though I was committed to breastfeeding prior to birth I didn't know how painful it could be and thank her for the unwavering support."

Self- identified as Black, had a planned hospital birth

What was the worst thing about your care?

Self-identified as White, gave birth in a free-standing birth center with an OB in New York

Self-identified as White, had a planned homebirth

What was the best thing about your care?

"Doula support at the birth in a calm, safe, and desired birthing center where my experience was honored."

Self-identified as Black, gave birth at home (unplanned accidental or enroute)

"My midwives were caring and passionate in their work. They respected my birth plan and always had the time to talk to us at great length during prenatal visits."

Self-identified as Asian, had a planned homebirth

"My midwife is amazing. She was hard to find because there are not many midwives in this area. She actually drove 2 hours over a mountain pass (one way) for all visits and for the birth."

Self-identified as Black Caribbean, had a planned homebirth

"The midwife who was on duty the night I went into labor. She left me and my husband and doula alone in the bathroom/shower and let my labor progress naturally without intervention."

Self-identified as African American, had a planned hospital birth

Self- identified as Black, had a planned hospital birth

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