We ride for the South. Don't you?
"First of all," Afua said, pointing at her sheer maxi skirt, "don't ever wear this again."
"Okay," said Malea.
"You can't dress like that in front of pregnant people. They're gaining weight and they don't like it and they don't want to see you wearing hot skirts and feeling all cute."
"Second of all, I don't take students. Because I have very high expectations."
Malea Hardeman was terrified of this woman. She also knew immediately that she wanted to move to Houston and work with her. It was here, at The Birthing Place, with the help of Afua Hassan, that Malea would begin training to be a midwife.
Yet Afua said she didn't take students. After the initial shock subsided, it occurred to Malea that Afua might be bluffing. So she kept asking questions, and they talked a good while there in the parlor where Afua usually meets with her clients. It's a cozy room with rocking chairs, a water dispenser, a basket of Legos. When you sit in one of the rocking chairs, you face a massive mural of a beautiful Black woman sprawled out, holding an ankh in her right hand, the head of her baby coming out into the hands of a midwife wearing white gloves, adinkra symbols flittering around them like moths. A few months ago, one of Afua's prospective clients thought the symbols were satanic and, upon noticing them, jumped out of her chair and ran out.
Malea stayed in her chair. Towards the end of their conversation, Afua told Malea that if she moved to Houston, she could be her student. And that's what she did.
Malea has wanted to deliver babies since she was little. A few months before her interview with Afua, Malea arrived at the University of Hartford intending to prepare for medical school and eventually become an OBGYN. But then, during the holiday break after her first semester, she interviewed a local obstetrician and grew uneasy without really understanding why. There was just something inherently "top-down" about obstetrics that gave her pause. The obstetrician noticed and said, "You don't sound like this is what you really want to do. Maybe you should look into other options." Maybe midwifery.
Malea took the next semester off. Her aunt in Houston, the funky Afrocentric hippie in the family, had been a client of Afua's, and suggested that Malea talk to her. Malea learned that Afua had, like her, initially planned to become an OBGYN, but then became interested in midwifery. At that time, midwifery was illegal in Afua's home state of Connecticut, but she met a midwife who invited her to apprentice under her in Houston, where it was legal.
Her friends were befuddled. She told them she'd found something called midwifery and it might be the love of her life. Her mother was concerned. "Don't be a hippie," she told Malea. "Hippies don't make money." She forwarded her daughter articles about how much money obstetricians make. Other folks asked Malea who she thought she was. "Do you think you're White? Because you're not White."
"Yes," she said. "I know."
Be honest, when you picture a midwife in 21st-century America, you probably picture a White woman with White clients. Home births, water births, birth centers, midwives, doulas, unmedicated labor, placenta encapsulation—the whole natural childbirth movement—isn't it all for rich White people? That's certainly the stereotype in popular culture. In a recent episode of Inside Amy Schumer, four wealthy pregnant women—three White, one Korean-American— drink cucumber water and discuss their birth plans, each woman trying to one-up the others in how arcane and expensive her birth will be. One plans to stuff rose petals up her vagina; another will have a water birth with "gender-neutral barley" in place of water; another will give birth on a Tibetan mountaintop, with a Sherpa for a doula.
The natural-childbirth movement is indeed overwhelmingly White. The number of births presided over by midwives has nearly tripled in the United States since 1990 (from 3 to almost 9 percent), but most of the growth has been within the White population. A White woman is four times as likely to have an out-of-hospital birth as a Black woman, and less than 2 percent of midwives in the United States are Black. In fact, Afua Hassan is the only Black midwife who owns her own practice in the Houston metro area, home to more than one million African-Americans.
This racial disparity is particularly striking because, until the early 20th century, most babies in the South were delivered by Black midwives. Enslaved women squatted under White women to catch their future masters, and Black women were still catching babies decades after the Civil War. Then the rise of modern obstetrics around the turn of the 20th century devalued midwives' work. Doctors decried midwives as "filthy," "ignorant," and "meddlesome." State legislatures began requiring midwives to attain licenses and undergo inspections—to make sure, for example, that a midwife wasn't carrying any herbs or roots in her bag. Gradually midwives were regulated out of existence. They lingered in rural pockets of the South until the introduction of Medicaid in 1965, which subsidized hospital births and therefore disincentivized out-of-hospital births.
Around that same time, many within the women's rights movement and the counterculture began to reject what they saw as the over-medicalization of birth. They believed the hospital birth robbed women of their autonomy and infused a beautiful, natural event with shame and fear. The Farm, a hippie commune founded in 1971 in rural Tennessee, established one of the nation's first out-of-hospital birth centers. The midwives, led by Ina May Gaskin, were nationally renowned for their low C-section and episiotomy rates, their virtual nonuse of forceps, and their success in performing breech births and VBACs (vaginal birth after cesarean). Soon evangelicals made strange bedfellows with hippies; they saw natural childbirth as a way to affirm God's wisdom.
The natural-childbirth movement has been, for the most part, a movement by and for college-educated White people. Moreover, in their efforts to relegitimize midwifery and out-of-hospital births, supporters and participants have usually used the language of consumer choice. Women ought to have the birth they want—or to put it another way, they ought to have the birth they're willing to pay for.
So, rather curiously, the out-of-hospital birth has become a luxury. Clients often have to pay out-of-pocket or know how to navigate oceans of red tape to get coverage. Afua charges $4500 for a home birth and $4000 for a birth at The Birthing Place, though she offers a discount to clients eligible for Medicaid and sometimes takes on a teenaged client pro bono.
A brief history of her clientele is revealing. When she first began working as a midwife in the mid-1980s, nearly all her clients were White. In the 1990s, she began to attract Latino clients, mostly from the professional class. Only in the past decade has she started getting a lot of Black clients, and even they skew wealthier and more educated. Now a plurality if not a majority of her clients are Black, though she still gets many White and Latino clients as well as a few Asian-Americans. My wife and I were clients of hers, and though we're not exactly wealthy, we're college-educated and White.
If an out-of-hospital birth can be expensive, it's also expensive to become a midwife. It costs money to get the training, to run one's own practice, to buy or rent the space for a birth center. Afua can only pay the bills because she lives and works in the same building—she runs The Birthing Place on the first floor and lives on the second and third floors. (She likes to joke about her daily "commute.") She was also able to buy the property for dirt cheap because it was abandoned, a former crackhouse. The renovation cost more than four times as much as the actual property, and she still spent less than $200,000 total—a pretty good deal in the seller's market that is Houston.
But it's not just market forces that make it hard for a midwife of color. She's met Black women who have recently given birth and are astonished to learn about The Birthing Place, because they had called other birth centers asking if there were a Black midwife in the city and were told "no".
Afua's also surprised by how many people decide, after interviewing her, to go all the way out to a suburban birth center when they live closer to her. (The Birthing Place is the only birth center inside Loop 610, an area the size of Milwaukee with a population the size of Kansas City.) She's even more surprised when, after giving birth, some of those new mothers call her seeking comfort and advice. "You're so friendly," they tell her. "But you didn't give me the money," she tells them. She won't be their mammy for free.
Some of Afua's friends tell her it's not the color of her skin that turns people away, it's where her practice is. The Birthing Place is in the Third Ward, the center of Black Houston, where shotgun houses and you-buy-we-fry fish markets abound. Having a Black midwife is one thing; having your baby in a Black neighborhood is another.
Indeed, when Afua first considered buying the house in 1995, her mother urged her to look at property in Pearland or one of the other southern suburbs. But Afua grew up in a neighborhood like this. She thinks of herself as a neighborhood midwife. And to move now would mean "catering to people who aren't really my clients." She likes knowing that her clients are the kind of people who are comfortable coming to the Third Ward. In any case, she can pay the bills. "And I'm evidently not starving because I ain't lost no weight."
I ask Afua what exactly it means to be a neighborhood midwife. "Well," she says, "I have clients who don't have enough food." One client didn't have a car and bought most of her food at the dollar store. There are women who always come to The Birthing Place hungry, and the prenatal meeting is not much more than a meal. While we're talking, a pregnant woman wearing a blue sarong opens the door without knocking, and Afua tells her there's spaghetti upstairs. She says no thanks, she's already eaten, but points to the basket of Sun Chips in the corner and lets me know the basket is there because of her personal lobbying.
Afua emphasizes the importance of community to a happy, healthy birth. And a real community has formed of clients past and present, mothers pregnant and nursing, older siblings and fathers. Mothers get together and walk around the neighborhood, or they work out to a DVD titled Lose the Gut, Keep the Butt. They share advice—how to treat chapped nipples, easy meals to cook and then put in the freezer for when the baby comes, what app to use for timing contractions. The fathers get together too; I went to one, and we spent an eerie amount of time talking about vasectomies. Afua calls this community "The Tribe," and she sees it as an antidote to the hospital's atomization of the family (where, Malea says, "x plus y plus b-squared equals this baby") and to a tendency within the natural-childbirth movement to talk so much about empowering the mother that she feels like she has to do everything on her own.
Afua also conducts her clients' prenatal visits with a communal focus. She doesn't just ask the pregnant mom how often she's pooping—and she does do that, every damned time—she asks if the mom and dad are having sex, whether Grandma is on board with a home birth, how the divorce in the family is going, what the older sister thinks about all this. Afua believes this holistic approach is particularly important for women of color, who have to deal with "a whole nother level of stress on top of everything else"—namely, racism.
The maternal mortality rate for African Americans is more than three times greater than for White women, and the infant mortality rate for Black babies is more than double the rate for White babies. If African Americans were their own country, their maternal mortality rate would tie with Moldova for the 71st lowest (in other words, worse than Sri Lanka, Malaysia, or Uzbekistan) and their infant mortality rate would tie with Libya for the 75th lowest (worse than Thailand or Botswana).
Though public health experts are still researching why these rates are so high, Afua places the blame squarely on systemic racism. From being followed around every time you're buying makeup to having to work twice as hard so employers don't think you're lazy, racism imposes a psychological toll, to the point where it's no longer just psychological. Afua has two sons, 19 and 20, and she's taught them exactly what to do if a police officer pulls them over—knowing full well they can do exactly what they're supposed to do and still get shot. "And we have all that inside us, and it doesn't go away when we're pregnant, and it's still there inside us while the baby's growing."
Even in the doctor's office and the hospital, Black women are often ignored and dismissed. "We're not heard." One client came to Afua 15 weeks into her pregnancy, anxious because her partner couldn't find work and she was struggling to support both of them, much less a baby as well. When they weighed her, they found she'd already gained 50 pounds. 50 pounds in 15 weeks.
"You've been going to the doctor, what'd the doctor say?"
"Nothing," the client said.
"Why do you think that is?"
"I don't know."
"Because he already knows, you a big girl, he's gonna cut it out. He don't have to talk about your diet or how much water you drink. He's written you off."
Afua doesn't think having more Black doctors solves the problem, anymore than having more Black police officers solves our criminal justice problems, because the system itself is the problem. That's partly why she decided to take on Malea as a student, and why she and other midwives in Houston raised funds for a scholarship for Black women training to be midwives. And that's why she keeps The Birthing Place going, even when the stream of clients dries up from time to time.
Afua discovered the house that became The Birthing Place the night before she gave birth to her third child Atiba. She told her husband, "Take me for a walk, I'm tired of being pregnant." They turned onto Barbee Street and there it was. She'd already been looking for a house to buy, so the next morning they went back. Her husband had to break in because it was all boarded up. They called the number of the guy who owned the property, but there was no answer—no answer, that is, until he called back that afternoon, when Afua was in labor. She grabbed the phone and told him, "As soon as I drop this baby I'm gonna call you back."
Towards the end of our conversation, I ask Afua about the mural on the wall—the woman giving birth, and below that image the same woman holding her baby in a white cloth. She tells me it's an ode to her daughter Maya, who "transitioned" a few years ago. It takes me a beat to realize she means Maya is dead. Cancer. I then realize the mural is based on photographs of Maya's own birth. And somehow The Birthing Place makes a little more sense. The house is suffused with love, but it's a love tinged with loss, as is every birth. At its consumerist worst, the natural childbirth movement suggests you can have a child without pain or sacrifice, so long as you have the right essential oils and the right Spotify playlist. Afua doesn't play like that. She wants her clients to "feel the vibration of it all." Not just "good vibes": the vibration of it all.
"The Birthing Place," Malea says, "figures out what you need it to be." Though she's no longer working there, it was what she, and the midwife she's working to become, needed. "It's a living breathing thing to me," she says. "I love it like it's my baby. I love it like I started it."
She smiles. "Though I definitely didn't and Afua will let you know."