In many of the photos from the first few hours of her son's life, Dairian Roberts’ eyes are closed. Even as nurses attempted to latch her newborn onto her breasts, Roberts was barely awake, groggy from anesthesia after hours of exhausting labor and, ultimately, a cesarean section.

"I don't remember taking any of them," the 32-year-old told TODAY.

When Roberts got pregnant again last year, the idea of returning to the hospital filled her with fear.

She had heard plenty of stories of Black women dying while giving birth, or afterward due to complications that went unnoticed. They’re not just stories: The U.S. has some of the worst maternal mortality and morbidity rates in the developed world, and minority women are especially at risk. Black and Native American/Alaskan Native women are two to three times more likely to die of pregnancy-related causes than white women, according to the Centers for Disease Control and Prevention. Roberts had memories from her own “traumatic” experience in the hospital: how her hand was so sore from a clumsy IV insertion that she could barely hold her son after he was born; how a doctor failed to warn her before inserting a flush into her vagina in an attempt to clear away some meconium; how the staff called the police when her husband refused to leave the floor during her epidural, she said.

Roberts decided to have a home birth with a midwife (a professional trained to provide pregnancy, childbirth and postpartum care, in any setting). The catch? The $5,600 price tag, none of it covered by her health insurance.

Dairian Roberts holds her husband's hand during her November 2019 home birth. *Photo by Matthew Orso*

Dairian Roberts holds her husband's hand during her November 2019 home birth. *Photo by Matthew Orso*

At the time, Roberts’ husband was a full-time student and her job as an occupational therapist was their family's only source of income. They would have to get creative. In lieu of birthday gifts last fall, she and her husband asked for donations to a PayPal account they set up for their midwife, who had agreed to a flexible payment plan. They did the same thing with gifts for Roberts’ baby shower.

Roberts also hired a doula (a trained professional who provides emotional and physical support during labor, but does not deliver babies), designing her a custom website as a barter for her services.

Meanwhile, Roberts took on additional therapy clients to pay for whatever her donations didn't cover, which meant she was working overtime for much of her pregnancy.

"The hustle in me is just there," Roberts said. "I knew what I wanted."

She knew what type of birth she wanted, but she didn't know if it would happen. While the rate of vaginal birth after C-section is increasing, it is still relatively low. In 2018, the VBAC rate was 13.3%, according to the CDC. Deep down, Roberts worried that her body "wouldn't know what to do," that she'd end up at the hospital anyway and all her efforts and fundraising would be for nothing.

That's not what happened, though. Last November, Roberts gave birth to her second child, a daughter named Koraji, at home in Los Angeles with her husband, two midwives and a doula by her side.

Dairian Roberts with her family. *Photo by Brandon Banks*

Dairian Roberts with her family. *Photo by Brandon Banks*

The cost of culturally appropriate care

Birth is expensive, period. One recent report found that the average amount spent on a hospital childbirth admission is $13,811, which includes both out-of-pocket costs and the amount paid by individuals' health insurers, though rates varied widely across the country. (And in general, a C-section is much more expensive than a vaginal birth.) The average birth center birth costs about $7,400, according to 2016 data from the American Association of Birth Centers, although the organization pointed out that the figure can change greatly from year to year. And a home birth might cost anywhere between $3,500 and $7,500; the most common amount midwives told TODAY for this story was $6,000.

While research shows that the overall cost of midwifery care is generally lower than the overall cost of obstetric care, that’s not always reflected in what the patient pays. For example, moms may discover that their health insurance plan completely covers maternal care with an obstetrician in a hospital setting, but does not fully cover out-of-hospital midwifery care at a birth center or at home.

Yet many women are willing to take on the costs. Conscious of rising maternal mortality rates and also hesitant to birth in hospitals during the coronavirus pandemic, some women of color in particular are taking control of their birth experiences — no matter the price.

"It is important for people to have a place for birth that is not the same as the place people go when they're sick."

“The awakening around racial consciousness coupled with the pandemic is (showing) that it is important for people to have a place for birth that is not the same as the place people go when they’re sick,” said Leseliey Welch, a former public health official and the co-founder of Birth Detroit, a community-based midwifery care center in Detroit, which aims to open a freestanding birth center next year.

Char'ly Snow, a midwife and one of the co-founders of Birth Detroit, at work during a recent appointment. Photo by Jason Walker

Birth workers are doing their part, too, by finding ways to work with insurance companies or slashing their fees so drastically that they're basically working for free, all in an effort to make their services more accessible.

Some have even begun working with incarcerated women. Twice a week, doulas from Ancient Song, a doula organization in Brooklyn that aims to reach low-income families and women of color, visit the notorious Rikers Island jail complex in New York City, to provide childbirth education, prenatal support, lactation consulting and more, although the program is temporarily on pause during the pandemic.

In an effort to make sure their services aren't reserved for only wealthy, mostly white clientele, many doulas also work on a sliding scale. Daisy Hamory is a doula in Los Angeles who often takes on high-earning, celebrity clients; she attended Hilary Duff's home birth in 2018. But many of her clients are also low-income.

"If someone has true financial need, especially if they're Black, indigenous (or a) person of color, I don't turn them away," Hamory said. "My full-paying clients subsidize that."

Recently one of her clients admitted she was scared to give birth in a hospital and of being encouraged to accept pain medications and medical interventions, some of them potentially unnecessary. Hamory asked her a question: If money wasn’t an issue, would she rather birth at home?

“Instantly she said yes,” Hamory said. “I said, we’re going to make that happen for you. I went on my social media and just crowdfunded with people in my circle. I raised enough money for her to hire a midwife in 48 hours.”

For medical reasons, Hamory’s client ultimately didn't have a home birth, but she was able to work with the midwife for more thorough prenatal care than she had been receiving, she said. Most importantly, the midwife was also indigenous.

“They shared a culture,” Hamory said. “She felt super at ease. She asked all the questions she needed to ask. She was never shamed for her living situation or any of the choices she made.”

The American College of Obstetricians and Gynecologists maintains that hospitals and accredited birth centers are the safest places to give birth, pointing out that while home births are associated with fewer interventions, they’re also associated with increased risk. Midwives who attend home births stress that they are not for everyone, and that they’re trained to know when someone needs to “risk out” to hospital care, as in the case of Hamory’s client.

Shocked by how quickly the donations poured in, Hamory has since started a grassroots scholarship fund for future clients in need.

"There's an abundance of money here in Los Angeles," she said. "And at the same time, there's a lot of poverty. I think we can fill in those gaps as a community. Together, we can lift each other up."

Like Black women, indigenous women are also in the midst of a maternal health crisis.

American Indian and Alaskan Native women are 2.3 times more likely to die of pregnancy-related causes than white women, according to the CDC.

Their babies are worse off, too: American Indian and Alaskan Native infants are twice as likely to die from sudden infant death syndrome (SIDS) than white babies, and 2.7 times more likely to die from accidental deaths before their first birthday.

Navajo midwife Nicolle Gonzales conducts a critical congenital heart disease screening on a newborn, following a home birth. *Courtesy of Nicolle Gonzales*

Navajo midwife Nicolle Gonzales conducts a critical congenital heart disease screening on a newborn, following a home birth. *Courtesy of Nicolle Gonzales*

Nicolle Gonzales is a certified nurse midwife in Santa Fe, New Mexico, which means that she is a registered nurse who has also completed midwifery training. As one of only 20 Native nurse midwives in the country, Gonzales is one of the most vocal voices about the dangers plaguing indigenous mothers, recently speaking on the U.S. Commission on Civil Rights’ virtual briefing on racial disparities in maternal health about how she’s seen Native women be mistreated and denied pain medication while giving birth in a hospital. Gonzales, who is Navajo, believes the lack of respectful, culturally appropriate maternal care is one reason for the disparities.

She founded the Changing Woman Initiative to improve access to quality care for Native women. The problems her clients face are plentiful: Most live in poverty. Many suffer from physical or emotional abuse as well as trauma, or live in households with drug and alcohol abuse. Some have no transportation to get to or from prenatal appointments. In some cases, people from her organization travel three hours round trip to meet clients in pueblos in northern New Mexico.

Like Welch, Gonzales is also raising funds to open a birth center. In the meantime, she attends home births and has opened an easy access clinic, where women can receive prenatal and reproductive health services, with or without appointments, regardless of their ability to pay. Through grants, she also helps provide them groceries and supplements.

"Some of the homes we serve don't have running water or flushable toilets," Gonzales told TODAY. "How are we going to help these women if their basic needs aren't being met?"

One of her goals is to acknowledge Native traditions related to the birthing process, which she had noticed were largely ignored in hospital settings. As a Native woman herself, it’s vital that her clients feel their culture is being taken into consideration.

“Each tribe has its own belief system,” said Gonzales. “Being a Native, brown provider, knowing some of those nuances and unspoken protocols is key. So for me, engaging with a Navajo woman, we already have this basic understanding of our culture. She doesn't have to teach me anything.”

A call for more non-white midwives and doulas

Birth workers of all races told TODAY that the need for more women of color in their professions is one step toward solving the problems plaguing minority communities.

“This is work that has always been done by BIPOC women, and now it’s being done by white women,” said Sara Howard, a midwife in Glendale, Calif. “That has to change. And I’m a white woman doing the work! It is important to support funding streams for not only patients to be accessing this, but for more people to get into becoming birth workers. That saves lives, too.”

In addition to her work with Birth Detroit, Welch is also the co-founder of the Birth Center Equity Fund, which aims to grow the number of community birth centers led by people of color — currently less than 5%, according to its own research.

“The majority of birth centers in this country are owned by white women, and the majority of women who have access to them are white women,” Welch said. “And those centers are fed by funds from previous practices, family income, family gifts — all of these things that our racialized history around wealth and the economy has given people of color a disadvantage.”

Progress is being made, though. In October, midwives Kimberly Durdin and Allegra Hill opened the doors of their birth center, Kindred Space LA, in south Los Angeles. Specifically, they’re located in what the Los Angeles County Department of Health refers to as Service Planning Area 6 (SPA 6), which has both the highest rate of poverty in the county and the highest rate of infant death.

Before opening the birth center, Durdin and Hill operated out of another nearby space, where they conducted trainings for doulas of color and held parenting and childbirth classes, but did not deliver babies.

Kimberly Durdin and Allegra Hill during the construction of their new birth center in Los Angeles. Photo by Ahughesphoto

Kimberly Durdin and Allegra Hill during the construction of their new birth center in Los Angeles. Photo by Ahughesphoto

The birth center is a big step toward their goal of being able to accept insurance, including Medi-Cal, California’s Medicaid program.

“It’s wonderful when a person can say, ‘Great, here’s a check for the full amount,’” Durdin said. “But not everyone can do that. It’s really a travesty that your ability to choose the type of care you receive is contingent upon how much money you make and the insurance you have. We’re probably six months away from accepting Medi-Cal. It’s a process. But at some point we will have it, and it will make our care a lot more accessible, which is our goal as Black midwives.”

For now, their clients, mostly Black women, pay out of pocket. Durdin and Hill also work on a sliding scale and have some clients who find “grassroots” ways to pay their $6,000 fee. Many came to Kindred Space LA because they, like Roberts, know the statistics all too well — for example, that Black women with at least a college degree are 5.2 times more likely to die from pregnancy-related causes than white women with a similar education.

“Black women are super freaked out that they’re going to die right now in a hospital, because Black women are dying having babies,” Hill said. “This has been happening for a long time. Now it happens and you see the person’s picture and you know their name and you find out that they’re a doctor or a nurse and you start thinking, there is nothing that can protect you in a hospital. That’s what the data says. It doesn’t matter how educated a person is, what their socioeconomic status is, they have just as much chance to die in a hospital.”

The knowledge alone is stressful.

“A lot of times we have clients who have known people who have died in hospitals,” Hill said. “Then it’s unpacking that trauma. The fear is toxic. The stress is toxic. They need time and space to process through that stuff so they don’t have to process that when they’re having contractions.”

Durdin and Hill expect their first baby to be born at the birth center in January. Although they’ve been seeing clients there since October, in their minds a birth will mark the official opening — another solid step toward their mission of making women feel safe and supported during one of the most powerful, vulnerable times of their lives.

"We believe so much in the power of birth and the hormones that happen."

“We believe so much in the power of birth and the hormones that happen,” Hill said. “The mysticism and the magic of it is my favorite part, so just to have someone in labor, in the home we created for them for that purpose, it just makes my hair stand on end.”

Edited by Gabrielle Frank