Long before birth moved into the hospital, in communities all across the globe, there have been women serving women in the role of midwife, traditional birth attendant and crone to care for people through pregnancy, birth and the postpartum period.
The role of the midwife once celebrated and deeply respected, declined as birth moved into the hospital in the early 20th century in the United States and other places. Doctors began to attend almost all of the births and the experience and wisdom of the midwife was belittled and disrespected, made illegal in many states, and offered up as an example of inferior care. Instituted regulations made it nearly impossible for Black and indigenous midwives to practice in their own communities and the number of midwives available to support birthing families declined drastically throughout most of the 1900s.
In the United States, as fewer births were attended by midwives, more births occurred in the hospital while maternal morbidity and mortality for Black people and families of color experiencing mortality rates almost four times the rate of their white peers.
Current research informs us that midwifery model of care for births occurring in or out of the hospital is appropriate and safe for healthy, low-risk pregnant people with a certified professional midwife (CPM) or certified nurse midwife (CNM).
Doulas also recognize that the midwifery model of care is a valued alternative for healthy birthing families. It is important to have health care providers who share a culture with the people they care for and provide culturally appropriate, evidence-based care to their communities. The relationship that develops between a midwife and patient along with the respect for traditional practices creates a win-win situation for families and communities.
May 5th (yesterday) was the International Day of the Midwife and today DONA International would like to highlight a wonderful success story of Nicolle Gonzales, a Native American CNM working in her community to provide thoughtful and culturally appropriate care to the families who are most at risk of poor birth outcomes. Nicolle is the founder of Changing Woman Initiative, whose non-profit mission is to “renew cultural birth knowledge to empower and reclaim indigenous sovereignty of women’s medicine and life way teachings to promote reproductive wellness, healing through holistic approaches.”
Doulas and midwives, working well together improve outcomes and birth satisfaction. Join me and DONA International in honoring and thanking midwives for all they do all around the world and meet Nicolle, who is making a significant difference for many Native American families in her community as they welcome a new little one into the world.
Sharon Muza: Why do you believe it is important for people to have care providers who look like them and share their background, culture, and traditions?
Nicolle Gonzales: Western society would like us (Native people) to believe that those coming into our communities are the experts when in reality our own women carry so much knowledge and awareness of how to navigate our systems already while upholding invisible cultural protocols created by the communities they live in. A provider who looks like them and is from the community will have some of this knowledge already and won’t have to learn them all over again. Further, accountability to their community is greater then it will ever be to the medical system in which they received their training. Because they are forced to navigate between the medical space and the community space, it actually forces them to do a lot of internal work on how they are going to do the work because their communities WILL hold them accountable if they mess up or disrespect their people in the medical space. Clinics and healthcare centers don’t function in a vacuum, those brought up in the community who return to work as a healthcare provider are aware of the resources in the area and may already have these relationships established, rather than having to create them all over again. The relationships really support the continuity of care needed to support wellness for each person.
SM: How do you incorporate community values and ancient traditions into the modern and evidence-based care you provide to expectant families?
NG: I get this question a lot, actually. Families who want to incorporate indigenous knowledge and ways of being into their prenatal, birth, and postpartum care, generally navigate towards the care that Changing Woman Initiative provides. While I have had to personally do some work on what knowledge I carry as a Navajo midwife and a healer on the path, I usually will ask families what their birth traditions are and who their midwives are. I believe the way western society is set up is that one person holds all this knowledge, and that is not true in Native societies. In Native American communities, each person carries a small bit of information and knowledge, so it’s important for those who seek this knowledge to return to their communities and ask for it. It’s part of their development as well, to give an offering first to receive this knowledge and then to be open to receive it. This process alone counteracts the colonial thinking that “we” are entitled to this information because we are Native or because of our heritage.
It’s important to know that regional medicines are different depending on climate and history of who settled the region. Because New Mexico was settled by Spanish colonials, healing medicines intertwine with spanish way of healing. In my conversations with Pueblo elders, they remember when the communities were served by spanish healers who would serve as midwives too. In times of sickness, they shared medicines and methods of healing.
As a Navajo midwife who has worked in the medical system for over 15 years as a nurse and now a midwife and who actively participates in Pueblo community activities, I am still fine tuning the balance between navigating when to pull in aspects of western medicine. I believe Native American communities have been using traditional medicine for a long time, so for me- time is evidence it works. I don’t use the word evidence-based care when I talk to my community about this work, because it doesn’t mean the same thing it does to the rest of us.
The big question is “what does having a traditional birth look like to you?” This generally opens the dialogue between clients and myself about what they expect, what they know, and what aspects I can help bring in – either through local healers I know or the medicine I bring as a Navajo midwife. I never assume it’s going to look the same for each couple or person.
SM: What are families saying about the care they receive from your Easy Access Clinic and the providers who work there?
NG: While we are still growing and our communities are still coming forward to
access our care, many are very thankful and happy we are doing this work. We have had Native families come from Albuquerque to access our care, which is a 50 min drive away. Our busy day is Wednesdays because we have a medicine person there all day doing body work. Our current prenatal and postpartum clients also come on Wednesdays to get care with our medicine person. At this time, it’s just me providing midwifery care and well woman care alongside our medicine person. The goal of our care is not to be so busy we can’t spend quality time with each of our clients, even the ones who drop in to our Easy Access Clinic. So, we spend one to two hours with each client, if that’s what they need.
SM: Can you summarize some of the positive outcomes your organization is seeing for both maternal and infant morbidity and mortality? What kind of an impact is Changing Woman Initiative having on Native New Mexican and Alaska Native families?
NC: Honestly, the larger impact in this area is still too early to tell. We have birthed with five families since we opened our clinic in November 2018. However, the feedback we are getting from our current and past clients is they are very happy with the care they are getting with us and would not otherwise be able to get this kind of care anywhere else. For us to have a larger impact and further reach, we need funding to hire additional midwives, staff, and to grow our administrative team. I envision setting up field clinics in areas where access to midwifery care is limited and the wait times to see an OB are four to six weeks. We are still in the start-up phase of setting up a clinic and seeing what is working and what is not. I am recognizing deeper issues that are impacting Native American communities, which also contribute to Native women’s health and birth outcomes. We are not just focused on maternal and infant morbidity and mortality rates, because those have not changed in the last 20 years for us, despite all the new technology and changes in health policy. That tells me the eco-system needs change in Native communities so that birthing families are supported in many other ways.
SM: I believe that New Mexico has the highest rate of out of hospital birth in the United States. Are low-risk Native American and Alaska Native families choosing to birth out of the hospital?
NG: I believe like 1% of Native American families are choosing the home and birth center options to birth in New Mexico. There are many reasons why this percentage is so low for Native Americans. One big reason is the cost, although many midwives in NM can say “Medicaid covers home and birth center costs” the reimbursement rate for this option is like $1,400.00 when those providing care in these settings might charge $5,000.00 for their services. So the out of pocket costs for Native Americans who might want this option is still more money then they can spend. There are few CPMs or home birth midwives in New Mexico who will take a pay cut to take care of these families, but some do.
Also, the way Indian Health Services (IHS) is set up, Native American families will start care with them and the family will need to transfer to another provider around 28 weeks because IHS does not have birthing facilities. This shift in care location also makes it challenging for midwives to recoup insurance reimbursement costs for care provided because the global fee is broken-up into sections based on visit. Many times, Medicaid will deny paying the midwives who have taken over care after 28 weeks and it takes months to get paid for care provided.
There is also still a stigma around the “safety” of out of hospital births in Native American communities. The marketing campaign around why hospital birth was safer than out of hospital birth that was started in the 1950s when IHS came into our communities was very persuasive, by the 1970s, 99% of Native American women were birthing in hospitals.
SM: One of your core missions is to provide training opportunities for more Native American midwives who can serve their communities. What are some of the barriers you are facing as you work to meet this goal?
NG: The ten-year plan for CWI is to be a birth center dedicated to training and working with Native American/Indigenous midwifery students, however, our birth center is still in the development stages. We recognize our communities need midwives like yesterday, which is why we created a Fellowship opportunity for Native American/Indigenous midwifery students. Right now our Indigenous Midwifery Student Fellowship is still being piloted by a Mohawk midwife student. The fellowship provides a monthly living stipend, funds for travel to spend time with traditional medicine people of the students’ choosing, this is not something we find for them, it’s a relationship they have developed in their community with healers and want to spend more time learning those skills alongside them. They also get funds to pay for completion of their midwifery education. The fellowship costs about 45K dollars to support one student who is at the very end of completing their midwifery training, which is the most critical time for them and usually when their resources have run out.
Some challenges we have had with creating this fellowship is explaining the feasibility of fully supporting one student versus training ten students. Native Indigenous midwifery students need a lot of one-on-one support because they face challenges of finding training sites that understand the impacts of colonialism in midwifery education. Often times they are faced with racism in training sites that don’t acknowledge or understand Native peoples’ history. Spending time with medicine people and attending food sovereignty gatherings is also part of midwifery education, but not always recognized as part of the fabric of what is “midwifery education” outside of specific skills needed to be a midwife. Complex family structures impacted by trauma and lack of support are big barriers for Native Indigenous students to overcome. We hope to create an eco-system of support and relationships for each fellow as they ascend into their new role as community midwives.
Another challenge we are faced with in working to return Indigenous Midwives to communities is legislation and licensure around midwifery. There are no specific exemptions in New Mexico or other states that allow or support the autonomy of Indigenous midwifery. Many of us are forced to navigate current day education systems and make it work somehow and then return to our communities to put the pieces back together, while finding that health policies created through legislative bodies we weren’t apart of, further making it harder to serve our communities and make a living. Let’s just say there are many barriers and we are creating workarounds to support the return of midwifery knowledge and skills back Native American communities.
SM: If people are interested in supporting your organization, how can they help?
NG: Funding continues to always be our challenge. Donating to our website or current fundraising campaign “Birthing a Dream” supports our work. We are very conscious of how and where funds are spent. We see our work as also supporting local and regional Native Indigenous economies.
About Nicolle L. Gonzales
Nicolle L. Gonzales, (Diné – Navajo), is the Executive Director and Founder of Changing Woman Initiative, a Native American women-led health collective. Mrs. Gonzales received her Bachelor’s of Nursing and her Masters of Nurse-Midwifery at the University of New Mexico. She is a member of the American College of Nurse-Midwives and is certified with the American Midwifery Certification Board. She has over 12 years’ experience as a nurse and has worked as a Nurse-Midwife doing full-scope midwifery for the last 7 years. Through the years, she has worked on several community projects around birth equity and she has served as the founding board president and vice board president of two birth centers in NM. In addition to attending births, Nicolle was a contributing author to the “American Indian Health and Nursing” in 2015 and is a contributing writer for the Indigenous Goddess Gang online magazine, where she discusses indigenous birth, midwifery, ceremony, reproductive justice, and indigenous feminism.