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Working Towards Social Justice Through Midwifery and Black Maternal Health Advocacy

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Ebony Marcelle is a 2018 Duke-Johnson & Johnson Nurse Leadership Program Fellow

Black women in the United States die from pregnancy and childbirth related complications at three to four times the rate of white women. In the nation’s capital, one midwife is determined to change that.

Meet Ebony Marcelle, 42, midwifery leader and tireless maternal health advocate for Black women. As Director of Midwifery at Community of Hope's Family Health and Birth Center in Washington D.C., one of five federally qualified health centers in the country that includes a birth center, Marcelle has created a maternal health program focused on saving the lives of Black mothers.

The Community of Hope midwifery model provides an out-of-hospital birth option in coordination with local physicians, perinatal care, maternity group sessions as well as a seamless transition to family practice providers and referrals to resources after the baby is born. By housing essential health services including maternal health services in one place, the health center aims to meet families where they are, making sure the entire family’s health needs—from diapers to dental care—are addressed.

Marcelle describes it as a progressive and innovative model to care for patients who come from the city’s most under-resourced wards with the lowest income. It is an approach that moves away from punitive practices such as turning away patients who are late and aims to build a supportive system for moms who need it the most.

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“Not seeing a patient because they are 15 minutes late is really outrageous,” says Marcelle. “Because if you depend on public transportation, it’s very easy to be late. Really working on creating better systems to help people get what they need and not treat them like they just made bad decisions is very important with the population we are taking care of.”

In recent years, Community of Hope has seen an increase of patients participating in its CenteringPregnancy® groups and forging bonds with other expectant mothers due to deliver around the same date. Participants typically experience better outcomes and the center has seen reductions in preterm birth rates and low birth-weight babies.

Importance of cultural congruency in creating safe spaces for families to engage in care

With more than 95% of Community of Hope’s prenatal patients coming from African American families, most of whom are Medicaid recipients, Marcelle tries to hire a midwifery staff of mostly Black women.

“Cultural congruency is an important factor in helping folks feel safe,” explains Marcelle. “If a clinic doesn’t create spaces for people to be seen and doesn’t have providers that patients feel comfortable with, then it doesn’t matter that the clinic exists. To engage in care, considerations need to be made for patients to feel safe, to work on past traumas, to provide integrated behavioral health services. Having a baby and expanding the family is a huge milestone. Our midwifery model is designed to provide that space.”

While the leadership at Community of Hope fully supports implementing her recommendations, Marcelle is painfully aware that Black midwives only make up 2% of the profession.

“In my dream land of course we wouldn't be 2%, we would be at least a strong 50%. Then there would be enough Black midwives to take care of Black women in maternity care settings but that's just not the reality at this point.”

What is real, she adds, is structural racism in the field that health systems are only beginning to acknowledge and tackle. In addition to socio-economic and financial situations that put midwifery education out of reach for many potential Black students, everyday micro and macro aggressions can cause students to struggle in school and even later in their professional lives. Marcelle is grateful that several organizations such as the National Association to Advance Black Birth, of which she is a board member, and the National Black Midwives Association are providing scholarships and mentorship support to encourage more Black women to enter the field. Until then, Marcelle urges the dominant culture to keep working hard every day to be anti-racist.

“We also need more seats at the table,” says Marcelle, “African American health leaders make up a very small percentage of leadership in most places.” Marcelle has been trying to support, teach and groom other Black midwives to join her in articulating the complexities of midwifery and the unique struggles Black women face to survive in this country.

In 2017, on the advice of another Black midwife, Marcelle participated in the year-long Duke-Johnson & Johnson Nurse Fellowship Program. “It was an excellent decision because a lot of times many of us are in leadership positions because we are natural leaders and not because we were ever taught or trained. The Duke-J&J program gave me a lot of skills that I never had to help me become a more efficient and a stronger leader. The whole year was a great experience and I feel there should be more programs like that.”

Marcelle was recently inducted into the Washington, D.C. Maternal Mortality Review Committee that is investigating the district’s high maternal mortality rate. While a few other states have similar initiatives, most she notes are physician-led. The D.C. committee also includes nurses, midwives, social workers and doulas and Marcelle is excited to see what recommendations and interpretations will come out of this uniquely diverse team.

Addressing racism as a public health issue

With the CDC acknowledging racism as a contributing factor in maternal mortality, Marcelle feels she is finally gaining some support for what she has been “hooting and hollering about for at least a decade.”

It’s not a secret anymore that Black women experience earlier deterioration of health due to the stressors of racism, says Marcelle. “Racism has been a topic nobody would touch. We are finally facing the truth that bias and systematic institutionalized racism affects everything, and most definitely maternal mortality.”

Marcelle is encouraged by the current national awakening and conversation about racism and hopes it will shift how providers perceive their patients. “It is so easy for our health systems to dismiss a woman as not being engaged in her pregnancy care. Now maybe we won’t be so quick to pass judgment on a mother. Maybe the reason why she is not at her appointment is because your office closes at 4 and she can’t get off work, or maybe it is because you don’t allow her to bring her other children with her, or maybe she can’t afford to get across town because the aid she receives covers just her rent to the dollar.”

Marcelle reminds us that African American women also carry with them generations upon generations of trauma. Perhaps they have had poor experiences with the system in the past that make them afraid to engage in care. A very common concern Marcelle often hears from Black women is the feeling of not being listened to. It’s something she has experienced herself. Over the years, for example, healthcare providers would apply a great deal of coercion with contraception and family planning without any consideration for the patient’s desires.

“There is so much rooted in slavery and white supremacy that we don’t like to acknowledge,” she says. “Some of the professionals we have put on pedestals trained consistently on slave women with no pain medication. It’s very easy to say, well that was then, but a research study done just a couple of years ago, in 2015 or 2016, found that many health providers thought Black people have thicker skin and a different level of pain tolerance.”

The uncomfortable conversations happening around her give her hope. Marcelle is teaching a class on racism and health disparities in Georgetown University’s midwifery program. It’s a small group of midwifery students she educates and a small number of families she cares for in her practice, but they are small steps toward progress, and she reminds everyone it is continuous and consistent hard work.

Midwifery, especially Black maternal health, is her expertise and she is adding racial equity in public health to her repertoire of work. By focusing on populations most in need she has turned her passion into a fight for social and reproductive justice.

Racism is exhausting, she admits, but so much more still needs to be done and she plans to keep leading and advocating on the front lines. She is thankful for her tribe of midwifery colleagues and mentors who have been out on this social justice movement before her.

As a new mom to a three-month old daughter herself, she knows this is a fight every bit worth fighting for.