Tiana Hylton had two reasons for not wanting to give birth to her first child at a hospital last April.

“The first reason was because of the pandemic. Everything was so chaotic and scary. The second reason was because I am a woman of color. That’s what I was really afraid of,” Hylton, a 30-year-old Los Angeles native, told Cronkite News.

She knew the risks – Black women face a maternal mortality rate three times greater than white women, and Black babies face an infant mortality rate twice as high as white babies – and they weighed heavily on her. Those statistics, added to concerns about COVID-19 in hospitals, were enough to make her seek the help of a midwife and a doula. She gave birth to a healthy baby girl at home on April 5.

“I had always wanted a water birth, but at first I couldn’t find a midwife in my area in my price range, so I kind of gave up hope,” Hylton said. “Then the pandemic started and I began to worry even more because I didn’t want to go to the hospital.”

Hylton wasn’t the only pregnant woman wary of visiting a hospital during the COVID-19 pandemic, which has cost more than 206,000 American lives. Although there isn’t much hard data tracking at-home births since the pandemic was declared in March, Los Angeles County health officials, doulas and midwives in LA told Cronkite News they have seen increased demand, and there’s anecdotal evidence of a rise in demand in San Diego and elsewhere.

Concerns like Hylton’s are well known at the Los Angeles County Department of Public Health, which reports that the disparity in Black infant mortality has remained static for decades. Even in typical years, Black women are most likely to consider a midwife at birth compared with other races, according to the California Department of Health Care Services.

Black mothers may also fear for their own lives. Black women have a maternal mortality rate of 37.3 per 100,000 live births, which is more than twice the rate of white women (14.9 per 100,000 live births), according to a 2020 report from the Centers for Disease Control and Prevention.

“Modern European medicine has always been against us,” Hylton said, referring to Black women. “A lot of (women of color) don’t make it through childbirth.”

COVID-19 further compounded fears among expectant mothers and midwives, said Deborah Allen, the deputy director of the county Department of Public Health.

“It has certainly affected women’s psychology,” she said. “Earlier in the pandemic, the hospital was about the riskiest place you could be. But home can be safer or riskier, depending. How crowded is home? Are people wearing face coverings and washing their hands? It really depends on the specific circumstances and who’s in the household.”

She said the idea of going to a hospital still makes some women uncomfortable, especially because COVID-19 precautions in hospitals have changed birth plans.

Some women plan to have both a doula and a partner at their birth, but some hospitals are restricting the number of people who can attend a birth to one, Allen said, so doulas can’t always attend.

A doula – which is Greek for “handmaiden” – is a trained professional who provides continuous physical, emotional and informational support to a mother throughout her childbirth, according to DONA International.

Restrictions in place for COVID-19 have left doulas, who often support women in hospitals, in limbo as they try to adapt to supporting women in birth without being physically present. Allen said hospitals are promoting telemedicine as an alternative to in-person doulas.

Although doulas are not medically licensed, as midwives are, clinical studies have shown that their attendance at birth can be a positive experience for the family.

Many midwives start out as doulas. Christian Toscano worked as a doula for five years in LA County hospitals before opening her own clinic, Fertile Moon Midwifery. The discrimination she witnessed at hospitals was part of the reason she stopped working at hospitals.

“I saw my Black clients being coerced quicker into cesarean sections, coerced into interventions that weren’t necessary,” Toscano said. “I saw women discharged from cesarean sections without pain medication. Black women. They are in agony.”

County hospitals in South Los Angeles have a troubled history when it comes to serving their largely Black and Latino communities, including the closure of parts of the Martin Luther King Jr./Drew Medical Center more than a decade ago. The Los Angeles Times reported about serious lapses in care that resulted in patient deaths in Pulitzer Prize-winning reporting that reaffirmed and revealed horrors, and helped shape these fears.

Toscano, who worked primarily with young, pregnant homeless women, said she couldn’t pick the most extreme example of the discrimination she witnessed because there were so many. Some of the violence and disregard she saw is part of the reason more Black women are choosing at-home births with doulas and midwives, she said.

California isn’t the only state with alarming birth mortality statistics among minorities.

Amy Tinney holds conversations between notification pings from her phone, often from women in labor. She is from Arizona, where Native American mothers share strikingly similar mortality statistics to Black women in Los Angeles. She worked in labor and delivery in Tucson and got her license for midwifery in Los Angeles in 2009. She now works as a private midwife and is the clinical director at Gracefull Birthing Center in LA.

Tinney said many women of color gravitate toward midwives because of culture and an inherent fear and mistrust of hospitals.

“It’s also how they grow up, and trust birth,” Tinney said. “They’re treated differently going into the hospital.”

That’s one reason Viergeni White sought Tinney.

From distress to doula

Inside a rundown building in downtown Los Angeles a few years ago, Viergeni White and her husband were greeted by stoic staff members and an outdated TV blaring Russian programs in the corner. The TV was one of the only pieces of technology in the building.

Uninsured and lacking options, she sat down with her husband.

“I don’t know why. I don’t want to be that Black girl and say it’s a Black thing, but it feels weird. I felt so … alone.”

She later found a better prenatal doctor and hired a doula, which she said helped her become confident and educated on what was happening with her body.
Most importantly, though, she didn’t feel alone.

White gave birth to her first baby in 2015 at a hospital far from her predominantly Black neighborhood in Baldwin Hills, in hopes of finding a more attentive staff. The day she gave birth, White was concerned and confused when medical staff told her she would be discharged but they wanted to keep her baby another day for blood tests.

“To separate a mom and a baby, that should be a very careful decision to make,” said White, who pushed until the hospital let her stay until her baby could leave with her. It was a confusing experience that left a lot of unresolved questions.

White didn’t give birth during COVID-19, but her journey for quality prenatal care led her down a path familiar to her friends.

“I had five or six friends who were pregnant at the same time as me,” she said. “Almost all of them were Black. Every single one of them did not birth in a hospital near us.”

White avoided complications during her hospital birth, but she said the experience of an miscarriage in 2018 lit a fire under her to help other women.

One month after her miscarriage, she began her training to become a doula. Now, she works to help women navigate healthy birth plans. The daunting statistic about infant mortality among Black women rarely leaves her mind.

“I did not believe that statistic when I first heard it,” she said. “To hear that … I still have my moments of denial, but that’s why I became a doula.”

She has helped Black women through births of every nature, including cesarean sections and other complications. Underlying health conditions that impact pregnancy are one reason the infant and maternal mortality rates are so high for Black women.

On the front lines: Legislation and education

The U.S. Department of Health and Human Services stresses that because Black women have a higher chance of developing chronic diseases associated with pregnancy-related mortality, it’s critical they have constant support and education throughout their pregnancy to improve outcomes. Compared with white women, Black women experience higher mortality from cardiomyopathy, hypertensive disorders of pregnancy and hemorrhaging, according to a study by the Women’s Health Research Institute in New York.

Allen, the LA County health official, said women often blame themselves and their behavior if they lose a baby.

“But on a group level,” she said, “there’s absolutely no evidence to support the idea that Black women do more risky things than white ones.”

In fact, she added, there’s evidence pointing in the opposite direction.

“For example, Black women who do not smoke have worse outcomes (from pregnancy) than white women who do smoke,” Allen said. “Race trumps smoking – and you know how bad smoking is.”

For all women, stress can impede easy births and cause complications in any stage of pregnancy. Stress stemming from racism, combined with the widespread concern about hospitals during the pandemic, make for a tense environment for some expecting mothers.

Regardless of the situation, Allen said, education is a good place to start combating health disparities. For the Black community, one of the most important parts of maternal education is learning to identify signs of preterm labor, which Allen called one of the biggest causes of Black infant mortality.

Allen said many are just beginning to understand how the racism Black mothers face exacerbates pre-existing medical conditions.

Senate Bill 474 was signed by Gov. Gavin Newsom last October to help address the disparity in maternal mortality rates among women of color in California. The law mandated implicit bias training for all perinatal health care providers in California as of January 2020.

Paving the way for mothers next-door

White said education was vital to her during her pregnancies, but she knows not every mother-to-be gets it. She lives in Baldwin Hills, California, which sometimes incorrectly is called Black Beverly Hills.

“It’s not that at all, it’s very diverse,” she said. “But it’s seated above an area we call the Jungles.”

She and her daughter listen to the Jungles some nights and have learned to decipher gunshots from fireworks. The neighborhood used to be called the Jungle because of the tropical foliage, but after the community protested that the name made it sound wild and animalistic, Los Angeles renamed the neighborhood Baldwin Village.

During her first pregnancy in 2015, White shopped in the area and saw lots of young Black mothers.

“I knew that if I was not educated myself, I could not imagine that any of those young women on the streets truly understood what they needed to do for their pregnancy,” she recalled. “You have to do a lot for yourself.”

In addition to “scary,” White used another word to describe her first delivery: overcoming. She felt even more in control of her second birth, where she was able to be at home.

“I got to take walks in the back yard when I was in labor. I got to sing in the shower with my husband, I was in my environment” White said. “That was rich.”

That power and strength she felt through her pregnancies, having a doula and becoming one herself is part of the reason she helps women every day. Since starting as a doula, she has helped numerous Black women through some of the challenges of pregnancy and fulfills one of the most important needs of pregnant women – to be heard, and to be seen.

“I think Black women seek the holistic approach because we want someone to see us, we want to learn, we want the full approach not the medical approach. We are not numbers, we are people,” White said. “Midwives do that. They see you.”