Building Bridges: Health Disparities, Midwives and Culturally Competent Care–and Education

This is a guest blog by Marinah Farrell, Certified Professional Midwife and Licensed Midwife, and one of the women featured in Midwives Address Health Disparities—the latest video from the new online series I am a Midwife all about midwives and what they do.  From the Midwives Alliance of North America.



Currently, in this country, the statistics are abysmal when it comes to maternal health care for communities of color and, correlated, educating maternal health care experts from those same communities. According to researchers, without sufficient health and racial diversity, the healthcare workforce isn’t able to fully serve the public (Cohen, Gabriel, and Terrell, 2002). They list four reasons: Cultural competency as necessary for effective communication and understanding across cultures. Second, minority health professionals are more likely to work in underserved communities. Third, health problems disproportionately affect underserved communities and so a greater focus on this population by researchers FROM the population being studied is imperative. Finally, diversity in the managerial and public health sector is necessary to plan for the future of health care in this country. “The researchers concluded that diversity in the education of health professionals is the necessary condition to augment the pool of competent and influential decision makers in all of the above areas of professional activity.” (Cohen et al.,2002)


Often the barriers to maternity care for patients of color or migrant populations are the costs, the lack of the health care infrastructure (including the lack of homebirth midwives to serve rural or tradition-based communities who desire an out-of-hospital birth), health care workforce shortages, language, the lack of cultural competency, and logistical issues such as transportation in cities with poor public transport system. Yet, of all these barriers, the most pressing is the lack of health insurance coverage – not just for those here without proper documentation but for the non-migrant population as well. “Health care insurance coverage is the most important predictor of gaining access to health care.” (CDC, 2004)


Other issues around access to quality maternal health care are not just those of race or ethnicity but also those of education, disability, sexual identity, and more.


What are some identifiable solutions to help in this maternal health crises in the U.S.?  There are many innovative models coming to the forefront to answer the issues of access to care and education for women of color. In addition to the underserved communities coming together to address political issues and sometimes its own health care (as is the case in many neighborhoods in Phoenix, where I live and work), culturally competent non-medical organizations are beginning to enter into community/organization relationships to focus more on health ‘equity’ and human rights. The thinking is that to focus on ‘equity’ will create more innovative models of healthcare and hopefully also address some of the issues for students of color to be more equipped to enter into health care fields. The advent of social media has also elevated the messages, awareness and education campaigns around education opportunities and medical care in a positive way for many who otherwise would not have access to the information. Indeed, recent studies have shown that African-Americans and English speaking, non-white Americans are the most active users of mobile web and cell phone ownership in much greater numbers than white users. As such, social networking has become a powerful tool. I know in my own community we can mobilize almost in minutes around a developing political issue and set up large health fairs via social media.


Finally, there is the cost associated with not caring for and educating our most impacted populations.  “Johns Hopkins University and the University of Maryland examined the direct costs associated with the provision of care to a sicker and more disadvantaged population, as well as the indirect costs of health inequities such as lost productivity, lost wages, absenteeism, family leave, and premature death. What they found was striking. More than 30 percent of direct medical costs faced by African Americans, Hispanics, and Asian Americans were excess costs due to health inequities – more than $230 billion over a three year period. And when you add the indirect costs of these inequities over the same period, the tab comes to $1.24 trillion. Eliminating health inequalities for minorities would have reduced indirect costs associated with illness and premature death by more than one trillion dollars between 2003 and 2006.” (Joint Center for Political and Economic Studies, 2009). And this, from the same study: “More than 59% of these excess expenditures were attributable to African Americans, who have the worst health profile among the racial/ethnic groups. Health inequalities among African Americans led to $135.9 billion in excess direct medical costs between 2003 and 2006. The potential direct medical cost savings for Hispanics was $82.0 billion over the same time period, representing 35.7% of the total direct medical costs of health inequalities.” (LaVeist, Gaskin, Richard, 2009)


So, what we have is a system in which not only do people of color suffer the consequences of a culturally incompetent workforce and lack of access to care, it also is costing our country a great deal of money to maintain this poorly functioning system.


Last night I had the privilege to sit with our local healthcare workers, or promotoras, who are trained from within their communities and identified by their peers as a health expert. In Arizona, where the immigrant population is terrified of getting deported and thus often doesn’t seek health care, the promotoras can be a bridge between the community and the health care system. Over dinner and discussion the question of why it is difficult to find maternal health workers “like us” came up and, as usual, all the reasons were discussed within the context of living somewhere that will also place you in a private prison and remove you from your family for not having documentation of U.S citizenship or residency. Our conversation made us realize that as a community – although we would continue to fight for a better model of care in maternal health – we were responsible to link to one another, as well as other allies in this movement, because it was an immediate and doable solution. We spoke about the many innovative models that are cropping up and the fact that international organizations are calling for more midwives to care for women in the Americas. We ate a healthy vegan meal and watched a birth movie together, women and men, and found that within our own communities we have many allies in the movement. As the U.S system continues to fail women and babies, and the education system for medicine makes it impossible for members of certain disenfranchised communities to learn, the midwives have a position into which they can build bridges and enter into the truly special place of community midwife through addressing the issues of access to education for student midwives from our most underserved communities and via alliances between midwives and community organizations serving the populations we wish to serve.


Marinah Valenzuela Farrell
, Certified Professional Midwife and Licensed Midwife with Freedom and the Seed Midwifery in Phoenix, Arizona


Marinah learned the art of midwifery through traditional midwives, as well as working in birth centers, public hospitals in developing nations, formal education in the United States and, of course, the many mothers she has served in her home birth practice. Marinah is licensed in Arizona and holds her National Certification and is a graduate of Arizona State University with a degree in Politics.


After partnering in a non-profit waterbirth center on the Mexico/Guatemala border and a short time in Uganda working at a primary care medical and birth center, Marinah returned to Arizona and established an active and diverse practice located in Tempe, Arizona. Marinah attends primarily homebirths but also attends, on occasion, families wishing to deliver at a local birth center in downtown Phoenix.


Marinah was raised in the traditional ways of her parents and was gifted to watch her grandfather and mother walk among plants, identifying their healing properties both in the mountains of Mexico and the deserts of Arizona. Her love for midwifery stems from this lifelong belief in the healing essence of the natural world, her strong political views regarding healthcare and informed consent, and the beautiful homebirths of her own children. Her current passions are linking Mayan/Mexican traditional healing with Chinese medicine as a way to further the healing potential of both practices, teaching students of midwifery and activism, and reaching out to individuals who do not generally have access to healthcare – whether through NGO work, free health work locally, or legislative and political work as a speaker or street level activist.


About Nicolle Littrell

Nicolle is a filmmaker, educator and activist. She produces films about birth options and women’s reproductive health through her indie film co., Woman in the Moon Films, located in Belfast, Maine. Her film series, “At Home in Maine” features authentic, intimate and artistic portraits of the homebirth experience. She is also adjunct Women, Gender and Sexuality Studies faculty at the University of Maine. Nicolle is co-producing “I am a Midwife” with the Midwives Alliance of North America.


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