Choice? Alternative Birthing Options for Black Women in the Southern U.S. From the 1970s-now

Haley O’Neill (’18) is a Biology and Gender, Women’s, and Sexuality Studies major from SE MN. After Grinnell, she is working with maternal healthcare and reproductive rights advocacy. She hopes to pursue midwifery or women’s healthcare policy.

The U.S. maternal mortality rate, in 2018,  is comparable to the rate in the 1970s. Approximately 700-900 women die in the United States each year, the highest of so-called “industrialized nations.” These numbers are exacerbated for women of color. For women of color and their babies, medical birth remains an unsafe arena due to many risk factors, racial prejudice, stereotypical approaches to the treatment of black bodies, and the assumption that white knowledge has more authority and validity than black knowledge. This article attempts to use the past to better inform our understanding of both birthing relations and birthing options for black women in the Southern US. For years, black slaves and southern communities in America practiced a woman-centric birthing approach until birth professionalization, eugenics ideology, and poverty-reduction rhetoric stripped power from traditional birth approaches. Current maternal care approaches disserve black women. By examining how these policies transformed historical practices for black women in the American South, we can better understand the role that institutionalized racism plays in shaping the autonomy black women in this region have over their bodies today. In turn, this understanding can inform attempts to re-think these policies and advocate for fair and adequate birth care for all women in the US. These discussions are framed in a historical context, in circumstances of the past: of forced sterilization and neo-eugenics movements, of the black birthing communities of the South, such as black grannies and midwives, and finally, in a discussion of current birthing patterns of women in the U.S.

To begin, we have to understand why birth care options are important to women. Birth is a fundamentally personal, intimate process that requires a safe, supportive space. Such a space can be easily influenced by both the presence and the perceptions of others, for better or worse. The nine-month gestation fosters a significant connection between mother and fetus/baby; decisions made during this time and, preemptively for during birth, are intricately related to a woman’s bodily autonomy and her authority to make decisions for her own body.

Nine-month gestation

Challenging these abilities can not only affect a woman’s physical, psychological, and spiritual well-being but also entirely negate her personal autonomy. Current literature reflects women’s concerns that their voices are not listened to [1]. Such questioning of women’s ability peaked with the professionalization of birth and the acceptance of non-physician male bodies into labor and delivery rooms during the 1930s-1980s. Today, it is continually discussed in contexts of reproductive rights.

Throughout the 1960s and 1970s, different minority groups—predominantly Native Americans, Hispanic women, and black women—were subjected to disproportionately high rates of sterilization, a majority of which were “coerced or involuntary” [2]. This equates to tens of thousands of sterilizations. Forced and coerced sterilizations are deeply entrenched in neo-eugenics ideology, but are cloaked in poverty-reduction rhetoric; the idea was that sterilizations would reduce the number of children poor women could have, in the long term, also reducing poverty. Realistically, forced sterilization and targeted contraceptive efforts served to protect the dominance and power of a white majority by controlling the birth rates of minorities. These efforts represented the fragility of white America and the false notion that eugenics perspectives were a horror of World War II: “coercive sterilization and no-procreation orders serve a form of old eugenic wine in new bottles” [3]. But why are these historical atrocities relevant today? Largely because these threats to a woman’s reproductive capacity still exist, arguably often just as directly. No-procreation court orders are one example of contemporary attempts to limit reproductive freedom, but so is the current presidency, so are the extreme funding cuts for women’s healthcare (i.e., attempts to limit abortion that drastically decrease the availability of all women’s health and reproductive rights, and so are the lack of appropriate maternal care for all women, but especially for women of color.

These efforts, under the guise of eliminating poverty and promoting good parenting, also preserved white racial purity and limited non-white women’s abilities to have children. Both the choice and the capacity of whether to become pregnant or to terminate a pregnancy were taken away from women—both of which attempt to limit a woman’s right to “have sex, to become pregnant, or to give birth” [4] not just to parent. Such actions raise fundamental questions about bodily autonomy and integrity and are not decisions individuals should make about anyone but themselves.

Bodily Autonomy

These efforts inherently imply “that a woman’s decision to terminate a pregnancy is a bad idea” [5], but also imply that poor black women are not “competent [enough] to control their own fertility” and that reproductive decision-making is an arena appropriate for government intervention [6]. Generally, advocates of such efforts justify their positions via desires to foster responsibility, via economic concerns or concerns for children [7]. But, in all reality, once sterilizations and no-procreation orders are instated, nothing has been accomplished to improve women’s “economic and social realit[ies]” [8]. This nuance reveals a historical contradiction: women are responsible for their own reproduction and this responsibility can only be guaranteed through sterilization or abstinence from procreating [9], but they also cannot be trusted to make appropriate, responsible decisions regarding their reproductive capacities. Thus, institutions ensured the outcome of such decisions through means that further marginalized certain groups of women while maintaining American ideals of self-sufficiency without providing tangible social support or resources to women [10]. These ideals have not vanished and are instead manifested through programs that narrowly target reproductive abilities of poor women rather than larger oppressive, social conditions [11].

The consequences of such herstories are evident in contemporary pregnancy statistics and maternal mortality and morbidity rates. Sterilization, coerced or voluntary, eliminated the possibility and choice of alternative biological birth for women. Historical exclusion from social and healthcare resources have manifested in significantly higher maternal mortality and morbidity rates for women of color and affected their familiarity with contraceptive knowledge and modes of communication with healthcare systems [12]. A Northwestern University study found that women who demonstrated low numeracy and literacy scores felt that they did not understand contraception and appropriate contraceptive uses well, which often resulted in unplanned pregnancies [13]. This analysis demonstrates how historic marginalization of non-white women, especially black women, from necessary health care resources can have long-lasting sequela. Currently, the birth care options available to women in the U.S. largely depend on socioeconomic resources, insurance type, geography, and proximity to care providers. Women of color do not appear to have drastically different birth options than white women– until insurance type is accounted for. Medicaid varies widely with geography and often economically coerces women using Medicaid resources into birth approaches “they find risky and objectionable” because Medicaid is usually limited to physicians or hospital-administered care [14]. Many midwife models are not permitted to accept Medicaid coverage or high-risk pregnancies, which severely narrows their clientele to a white-middle to upper-class cohort.

More women of color receive federal health insurance or federal aid than white women and thus, are limited by their insurance to certain care providers or structures. Some would argue that women of color do not have a choice, that extenuating social conditions eliminate all elements of choice. These individuals would argue that because black women experience greater amounts of physiological weathering due to daily discrimination, are 243% more likely to die from pregnancy or childbirth than white women, likely don’t have access to guaranteed unbiased, quality care, and are more likely to exhibit cardiac issues, they are likely to be considered high-risk pregnancies. This distinction limits the availability of a midwifery care model and dictates that women of color are cared for by an obstetrician, which generally means their care is located in a hospital setting, where they might be outside the realms of their personal authority, autonomy, and jurisdiction.

The inability of contemporary black women to access alternative birth models contrasts with historic birthing circles of slave communities and Southern black communities. Black midwives, or grannies, were revered by their greater communities of color and were capable of employing their “motherwit” to foster a woman-centric supportive environment for laboring black women [15]. Grannies were an act of resistance to white authority and patriarchy but also maintained collaborative relationships with white doctors and some slave owners. White society tried to replace uneducated granny midwives with black women of good standing [16]. Because grannies were able to identify with black women’s feelings of vulnerability, they were most equipped to attend to the physical and psychological needs of black women [17]. This dynamic became more vital in instances where black women had barely if any, authority in care approaches [18]. Today, black women continue to receive inadequate support during labor and postpartum periods [19] and experience challenges of their bodily authority—patterns that are not limited to just the South. One might argue that concerns about the health of women of color are still related to economic stability, echoing slave plantation perspectives and blatant historical racism [20]. However, given current mortality and morbidity rates for women of color, the past fears of black morbidity and mortality “holding back the nation” appear resolved or less worrisome to white society [21]. There are many reasons multiparous women, or those who have given birth before, more frequently choose midwives for subsequent births compared to first-time mothers [22].

Today, there are more birth options available than in previous times. But, this increased ‘choice’ is debatable for black women—societal marginalization severely influences how much choice black women have in their birth endeavors and care provider-client relationships. Studies demonstrate that the most influential factors of women’s birth decisions are the availability of birth care options and the economic feasibility of these options [23]. Women make individual decisions based on their perceptions of what is safe versus dangerous; most women want the safest birth option that best balances outcomes for their person and their baby [24].

Perceived Risks between Mothers and Babies

Women’s individual chances of accessing their desired birth place and care approach are related to how much their risk perceptions coincide with dominant medical understandings of risks associated with birth and birth pathology [25]. Ironically, contemporary medical practices fail to address the needs and specific challenges of black women, but also often create or contribute to these specificities.

White-middle to upper-class, privately insured, educated, and geographic proximity to healthcare are just some of the identities and privileges that influence a woman’s access to care. Black women have significant herstories of supportive, collective birthing efforts, but the licensing and formal training requirements of certified nurse midwives may have decreased the availability of this profession to women of color. Access to these supportive, culturally rich environments has likely decreased over time. Contemporary movements to increase black representation in midwifery and doula work may alleviate this gap. Healthcare has largely disenfranchised women of color, but especially pregnant women of color, a pattern of which is not limited to just the Southern U.S. or the past. Efforts to address these issues need to account for the historical context of forced sterilization and neo-eugenics movements, of black birthing communities of the South, and in discussions of current birthing patterns of women in the U.S.



[1] Yee, Lynn & Simon, Melissa. (2014). “The Role of Health Literacy and Numeracy in

Contraceptive Decision-Making for Urban Chicago Women.” Journal of Community Health 39: 394-399;

Panazzolo, Michelle & Mohammed, Ritchlyn. (2011). “Birthing Trends in American Society and

Women’s Choices.” Race, Gender & Class 18(¾): 268-283.

[2] Flavin, Jeanne, “Race Criminals”: Reproductive Rights in America” in Our Bodies, Our

Crimes: The Policing of Women’s Reproduction in America. (New York; London: NYU Press, 2009): 16.

[3] Flavin, Jeanne, “‘Breeders’: The Right to Procreate” in Our Bodies, Our Crimes: The

Policing of Women’s Reproduction in America. (New York; London: NYU Press, 2009): 41.

[4] Flavin, Jeanne, “‘Breeders’: The Right to Procreate” in Our Bodies, Our Crimes: The

Policing of Women’s Reproduction in America. (New York; London: NYU Press, 2009): 30.

[5] Flavin, Jeanne, “Race Criminals”: Reproductive Rights in America” in Our Bodies, Our

Crimes: The Policing of Women’s Reproduction in America. (New York; London: NYU Press, 2009): 22

[6] Flavin, Jeanne, “‘Breeders’: The Right to Procreate” in Our Bodies, Our Crimes: The

Policing of Women’s Reproduction in America. (New York; London: NYU Press, 2009):  37.

[7] Flavin, Jeanne, “‘Breeders’: The Right to Procreate” in Our Bodies, Our Crimes: The

Policing of Women’s Reproduction in America. (New York; London: NYU Press, 2009): 43.

[8] Ibid, 43.

[9] Ibid, 43.

[10] Ibid, 43.

[11] Flavin, Jeanne, “‘Breeders’: The Right to Procreate” in Our Bodies, Our Crimes: The

Policing of Women’s Reproduction in America. (New York; London: NYU Press, 2009): 48.

[12] Yee & Simon 2013

[13] Ibid

[14] Chasteen Miller, Amy & Shriver, Thomas. (2012). “Women’s Childbirth Preferences and

Practices in the United States.” Social Science & Medicine 75: 709-716.

[15] Smith, Susan Lynn. Sick and Tired of Being Sick and Tired: Black Women’s Health

Activism in America, 1890-1950, (Philadelphia: University of Pennsylvania Press, 1995): 46.

[16] Ibid, 46.

[17] Schwartz 185

[18] Schwartz 199

[19] Panazzolo & Ritchyln, 275

[20] Smith, Susan Lynn. Sick and Tired of Being Sick and Tired: Black Women’s Health

Activism in America, 1890-1950, (Philadelphia: University of Pennsylvania Press, 1995): 45.

[21] Ibid, 45.

[22] Panazzolo & Ritchyln, 276

[23] Chasteen Miller & Shriver, 714

[24] Chasteen Miller & Shriver, 712

[25] Chasteen Miller & Shriver, 715


Recommended Further Reading:

  1. Vandenberg-Daves, Jodi. Modern Motherhood: An American History. Rutgers University Press, 2014.
  2. Kluchin, R. Fit to Be Tied: Sterilization and Reproductive Rights in America, 1950-1980. New Brunswick; London: Rutgers University Press, 2009.
  3. Fraser, Gertrude Jacinta. African American Midwifery in the South: Dialogues of Birth, Race, and Memory. Cambridge: Harvard University Press, 1998.