We Refuse the False Choice: Mutuality, Birth Justice, and the Full Spectrum of Care

For generations, birth has been a shared story in my family; community hands, a midwife’s care, the guiding presence of Black doulas, sisters, mothers, and friends.

Adatina, known as Ma Powell, was a community midwife in Jamaica. She delivered my grandmother, Mary, and 18 years later, my mother, Lily, named for her small size at birth, after Mary endured malaria. Each generation learned by supporting the next, in community, long before systems formalized what they already knew.

1956: My Grandmother Mary in Nursing Training Stratford-upon-Avon, England

As part of the Windrush generation, my grandmother, Mary, migrated to the UK in 1955, where she trained as a nurse-midwife. She stood beside me when I had my first child. And I have no doubt she was there in spirit when I delivered my last, surrounded by love: my Black husband, my Black midwife, and Black doulas.

My youngest, Lilly, carries a small mark of that lineage, a mole on her arm, just like the one my grandmother had.

I had everything I asked for in that birth. Still, it was not an easy road.

2021 — Me, my last baby, my midwife, my doula

It is the truth we don’t say enough: even with access, knowledge, and support, the system is still fragile, and for too many Black families, it is failing.

We Refuse the False Choice

We have to stop accepting the false choice.

The false choice is the idea that we must choose between solutions: doulas or midwives, community-based care or clinical systems, innovation or tradition. In reality, outcomes improve when birth support and systems work together. It is a framing rooted in scarcity that fragments care, limits investment, and prevents us from building the full ecosystem families actually need.

• I believe that #DoulasAreForEveryBody; families need clear, accessible information about the role of doulas and how to access care.

• I believe in #BelovedBirth50by50; expanding midwifery care is essential to improving outcomes.

• I believe #WeWriteUs ; centering our stories is how we shape policy, practice, and systems change.

Mutuality rejects scarcity. It allows us to hold multiple truths and build multiple solutions at once. For Black maternal health, anything less than a full spectrum of care is not enough.

Black women do not experience inequity in one place. It shows up before conception, during pregnancy, at birth, and long after. It is shaped by the cumulative toll of systemic inequities, what Dr. Arline Geronimus named “weathering.”

The latest data makes this clear.

While overall maternal mortality in the U.S. has declined slightly, Black women continue to die at disproportionately high rates with limited sustained improvement. In 2023, Black women died at a rate of 50.3 deaths per 100,000 live births, compared to 14.5 for white women (CDC, 2024). In 2024, the rate for Black women was 44.8 per 100,000, compared to 14.2 for white women (CDC, 2025).

At first glance, this shift may appear to signal progress. But a single year-to-year decline does not represent meaningful or sustained change, particularly in a data system where reporting variability, delayed classification, and small population shifts can influence annual rates.

What has not changed is the underlying pattern: Black women are still dying at more than three times the rate of white women.

Even where overall rates improve, progress for Black women has remained uneven and insufficient.

It is not a marginal gap; it is structural.

Black maternal health disparities are not accidental or recent; they are the cumulative result of generations of policy, practice, and structural inequity. From the exploitation of Black women’s bodies during enslavement, to the systematic dismantling of community-based midwifery, to segregation, redlining, and ongoing disinvestment in Black communities, the conditions that shape pregnancy have never been equal. These forces show up in weathering, unequal access to care, environmental exposures, and persistent bias within healthcare systems. Even today, Black women with higher income and education experience worse outcomes than their white counterparts, underscoring that this is not about individual behavior, but about systems that shape risk long before pregnancy begins.

Black communities are navigating maternity care deserts, hospital closures, workforce shortages, policy instability, and persistent gaps in perinatal mental health care, all of which compound risk across the perinatal journey (HRSA, 2024; The Commonwealth Fund, 2024; Dossett et al., 2024).

So again, why are we still being asked to “just pick one” solution?

The Full Ecosystem

This is not an either/or moment. We need the full ecosystem working together:

• Midwifery (Certified Nurse-Midwives (CNMs), Certified Midwives (CMs), Certified Professional Midwives (CPMs))
• Community-based doulas
• Birth centers in communities with access gaps
• Perinatal mental health support
• Lactation support
• Integrated health care teams (aligned clinical partners)
• Continuity of care across conception, pregnancy, birth, and postpartum

The evidence is clear: outcomes improve when care is continuous, culturally aligned, and coordinated.

Doulas: Tradition and Pipeline

Doulas have always been part of birth. Long before formal systems, community support carried us through.

My work centers community-based doulas; trained, non-clinical birth workers rooted in and accountable to the communities they serve. They provide continuous emotional, physical, and informational support throughout pregnancy, birth, and the postpartum period, with a focus on culturally congruent care and continuity.

The evidence reflects what we’ve always known: continuous labor support is linked to fewer interventions and better outcomes (Bohren et al., 2017).

Doulas are also a workforce pipeline. Across many direct-entry midwifery programs, roughly 30% to over 60% of applicants or students have doula experience, a consistent, if not yet nationally tracked, pattern.

The lack of data is not neutral; it’s structural.

We are relying on a workforce we have not fully counted, resourced, or protected while designing systems that risk undermining the very autonomy that makes it effective.

We don’t need to choose between doulas and midwives. We need to invest in both, and the bridge between them.

Centering Community-Based Leadership

Community-based doulas are organizing because they have to.

They are ensuring the profession is not extracted, diluted, or defined without them. Efforts like the Community Birth Support Coalition have established core competencies grounded in cultural humility, accountability, reproductive justice, and continuity of care, and centering community-based birth workers in governance.

It is not just about training. It is about power.

And organizing requires resourcing.

If we expect community-based doulas to operate as partners in this ecosystem, they must be resourced as such, not treated as an add-on to systems that were never designed with them in mind.

Collaboration, Not Competition

We have to name the problem clearly.

The maternal health workforce is too often framed in competition:

Doulas vs. midwives. Community vs. clinical care. Continuous, relationship-based support vs. clinical intervention.

This is false and harmful.

These roles are distinct and complementary. When aligned, they create safer, more humane care.

Anything less fragments care for the very people we are trying to serve.

A Direct Call to Funders and Policymakers

If we are serious about changing outcomes, we must stop designing policy and funding strategies as if only one solution can win.

To funders and policymakers: do not break the ecosystem in the name of scale, simplicity, or speed.

Let’s be clear: this is not a call to further invest in the overmedicalization of birth. As new interventions emerge, we must ensure they do not come at the expense of community-based models that have long supported better outcomes. We must build what is next while strengthening what has always worked.

Scarcity-driven decisions across grants, reimbursement, and regulation fragment the ecosystem by:

• Pitting providers against each other instead of enabling partnership
• Privileging clinical systems while under-resourcing community-based care
• Forcing an artificial divide between workforce development and service delivery

It weakens the entire system.

We cannot afford to sacrifice one part of the ecosystem to sustain another.

And there is a critical point we must center:

When Black families are supported, outcomes improve, and the burden on crisis-driven healthcare systems decreases.

• Fewer complications
• Fewer costly interventions
• Lower long-term healthcare costs
• Stronger maternal and infant health outcomes

It is not only a moral imperative; it is sound policy and fiscal strategy.

What Must Happen Now

To funders and policymakers, the path forward is clear:

• Fund the full continuum of care, shifting away from overreliance on clinical systems by investing in midwifery, birth centers, doulas, and perinatal mental health as an integrated, community-centered whole.
• Design reimbursement models that support coordination and continuity, not fragmentation
• Resource community-based organizations as core infrastructure, not short-term pilots
• Invest in workforce data systems co-developed with Black, Brown, and Indigenous doulas with appropriate support, resources, and infrastructure for participation, while recognizing doulas as a critical part of the healthcare ecosystem.
• Ensure regulatory and payment systems do not exclude community-rooted providers
• Reinvest cost savings from improved outcomes back into community-based care and prevention

If we want different outcomes, we must fund and govern differently.

Conclusion

Mutuality is not a theory; it is a practice.

It is how our communities have always survived and, more importantly, how we create the conditions for joy and well-being.

The solutions exist. The workforce exists (albeit in need of expansion). Communities are clear about what they need.

The question is whether we are willing to fund and protect the full ecosystem without forcing it to compete with itself.

References

• Alio, A. P., Dillion, T., Hartman, S., Johnson, T., Turner, S., Bullock, S., & Dozier, A. (2022). A Community Collaborative for the Exploration of Local Factors Affecting Black Mothers’ Experiences with Perinatal Care. Maternal and Child Health Journal, 26, 632–640.
• Bohren, M. A., et al. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews.
• Centers for Disease Control and Prevention (CDC). (2024). Maternal Mortality Rates in the United States, 2023.
• Centers for Disease Control and Prevention (CDC). (2025). Provisional Maternal Mortality Data, 2024.
• Dossett, E. C., Stuebe, A., Dillion, T., & Tabb, K. M. (2024). Perinatal Mental Health: The Need for Broader Understanding and Policies That Meet the Challenges. Health Affairs, 43(4).
• Geronimus, A. T. (1992). The weathering hypothesis. Ethnicity & Disease.
• Geronimus, A. T., et al. (2006). Weathering and allostatic load. American Journal of Public Health.
• Greenwood, B. N., et al. (2020). Physician–patient racial concordance and birthing outcomes. PNAS.
• Health Resources and Services Administration (HRSA). (2024). State of the Maternal Health Workforce Report.
• Howell, E. A. (2018). Reducing disparities in maternal morbidity and mortality. Clinical Obstetrics and Gynecology.
• The Commonwealth Fund. (2024). Maternity Care Deserts and Access to Care in the U.S.