This Midwife Has Dedicated Her Career to Helping Women In Maternal Care Deserts

Billie Hamilton-Powell shares a first-hand account of the maternal health care disparities that minorities face in the U.S. and how she's doing her part to help.

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Photo: Courtesy of Billie Hamilton-Powell

Midwifery runs in my blood. Both my great-grandmother and great-great-grandmother were midwives back when Black people were not welcome at white hospitals. Not only that, but the sheer cost of giving birth was more than most families could afford, which is why people were in dire need of their services.

Several decades have passed, yet racial disparities in maternal health care continue — and I'm honored to follow my ancestors' footsteps and do my part in bridging that gap even further.

How I Began Serving Underserved Communities

I started my career in women's health as a maternal care nurse focusing on labor and delivery. I did that for years before becoming a physician's assistant in obstetrics and gynecology. It wasn't until 2002, however, that I decided to become a midwife. My goal was always to serve women in need, and midwifery turned out to be the most powerful avenue toward that. (ICYDK, a midwife is a licensed and trained health care provider with expertise and skills to help women have healthy pregnancies, optimal births, and successful postpartum recoveries in hospitals, health care facilities, as well as personal homes.)

After receiving my certification, I began searching for jobs. In 2001, I received the opportunity to work as a midwife at Mason General Hospital in Shelton, a very rural city in Mason County in Washington state. The local population at the time was about 8,500 people. If I took the job, I would be serving the entire county, along with just one other ob-gyn.

As I settled into the new job, I quickly realized just how many women were in desperate need of care — whether that was learning to manage preexisting conditions, basic childbirth and breastfeeding education, and mental health support. At every appointment, I made it a point to provide expecting moms with as many resources as possible. You could never be sure if patients were going to keep up with their prenatal check-ups simply because of access to the hospital. I had to create birthing kits, which contain supplies for a safe and sanitary delivery (i.e. gauze pads, mesh undies, clamp for the umbilical cord, etc.) just in case expecting moms were forced to deliver at home because of, say, the long distance to the hospital or lack of insurance. I remember one time, there was an avalanche that caused a lot of moms-to-be to get snowed in when it was time to deliver — and those birthing kits came in handy. (

Oftentimes, the operating room experienced huge delays. So, if patients needed emergency help, they were often forced to wait for long periods of time, which put their lives at risk — and if the scope of the emergency was beyond the hospital's patient care capabilities, we had to request a helicopter from bigger hospitals even farther away. Given our location, we often had to wait more than half an hour to get help, which sometimes ended up being too late.

While at times heartbreaking, my job allowed me to really get to know my patients and the hurdles that inhibit their ability to access the health care they need and deserve. I knew this was exactly where I was supposed to be. During my six years in Shelton, I developed a fire for becoming the best I could be at this job with the hopes of helping as many women as I could.

Realizing the Scope of the Problem

After my time in Shelton, I bounced around the country providing midwifery services to more underserved communities. In 2015, I moved back to the D.C.-metropolitan area, where I'm from originally. I started another midwifery job, and less than two years into the position, D.C. began facing significant changes in access to maternal health care, particularly in Wards 7 and 8, which have a combined population of 161,186, according to D.C. Health Matters.

A little background: D.C. has often been known as one of the most dangerous places for Black women to give birth in the U.S. In fact, it's even been "ranked the worst, or near the worst, for maternal deaths when compared to other states," according to a January 2018 report from the Committee on the Judiciary and Public Safety. And the following year, data from the United Health Foundation further demonstrated this reality: In 2019, the maternal mortality rate in D.C. was 36.5 deaths per 100,000 live births (vs. the national rate of 29.6). And these rates were significantly higher for Black women with 71 deaths per 100,000 live births in the capital (vs. 63.8 nationally). (

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Courtesy of Billie Hamilton-Powell

These numbers are difficult to digest, but seeing them play out, in reality, was even more challenging. The state of maternal health care in our nation's capital took a turn for the worst in 2017 when United Medical Center, one of the major hospitals in the area, shut down its obstetrics ward. For decades, this hospital had been providing maternal health services for the predominantly poor and underserved communities of Wards 7 and 8. Following that, Providence Hospital, another major hospital in the area, also shut down its maternity ward to save money, making this area of DC a maternal care desert. Thousands of expecting moms in the city's poorest corners were left without immediate access to health care.

Overnight, these expectant moms were forced to travel longer distances (half an hour or more) — which can be life or death in an emergency — to receive basic prenatal, delivery, and postpartum care. Since people in this community are often financially strapped, travel poses a huge barrier for these women. Many can't afford to have childcare readily available for any kids they might already have, further impeding their ability to visit the doctor. These women also tend to have rigid schedules (due to, say, working several jobs) that make carving out a couple of hours for an appointment even more challenging. So it comes down to whether or not jumping all of these hurdles for a basic prenatal check-up is really worth it — and more often than not, the consensus is no. These women needed help, but in order to get that to them, we needed to get creative.

During this time, I began working as the director of Midwifery Services at the University of Maryland. There, we were approached by Better Starts for All, an on-the-ground, mobile maternal health program with services aimed at bringing support, education, and care to moms and moms-to-be. Getting involved with them was a no-brainer.

How Mobile Health Care Units Are Helping Women In D.C.

When it comes to the women in underserved communities such as Wards 7 and 8, there's this notion that "If I'm not broken, I don't need to be fixed," or "If I'm surviving, then I don't need to go to get help." These thought processes erase the idea of prioritizing preventative health care, which can lead to a slew of long-term health problems. This is particularly true in pregnancy. Most of these women don't view pregnancy as a health condition. They think "why would I need to see a doctor unless something is overtly wrong?" Therefore, proper prenatal health care is put on the back burner. (

Yes, some of these women might go in for a preliminary prenatal check-up once to confirm the pregnancy and see the heartbeat. But if they've already had a child, and things went smoothly, they may not see the need to visit their doctor the second time around. Then, these women go back to their communities and tell other women that their pregnancy was fine without getting routine check-ups, which detracts even more women from getting the care that they need. (

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Courtesy of Billie Hamilton-Powell

This is where mobile health care units can make a huge difference. Our bus, for instance, drives right into these communities and brings desperately-needed quality maternal care directly to patients. We are equipped with two midwives, including myself, exam rooms where we offer prenatal exams and education, pregnancy testing, pregnancy care education, flu shots, birth control consultation, breast exams, infant care, maternal and child health education, and social support services. We often park right outside of churches and community centers throughout the week and help anyone who asks for it.

While we accept insurance, our program is also grant-funded, which means women can qualify for free or discounted services and care. If there are services we cannot provide, we also offer care coordination. For instance, we can refer our patients to providers who can administer an IUD or birth control implant for a low cost. The same goes for in-depth breast exams (think: mammograms). If we find something irregular in our physical exams, we help patients schedule a mammogram for low to no cost based on their qualifications and their insurance, or lack thereof. We also help women with existing diseases such as hypertension and diabetes get connected with health care providers who can help them gain control of their health. (

The most important factor, however, is that the bus provides an intimate setting where we are able to really connect with our patients. It's not just about giving them their check-up and sending them on their way. We may ask them if they need help applying for insurance, if they have access to food, or if they feel safe at home. We become a part of the community and are able to establish a relationship built on trust. That trust plays a huge role in building rapport with the patients and provide them with sustainable, quality care. (

Through our mobile health care unit, we have been able to remove a lot of obstacles for these women, the biggest being access.

With COVID and social distancing guidelines, patients are now required to book appointments beforehand, either via phone or email. But if some patients can't physically come to the unit, we are able to provide a virtual platform that allows us to bring care to them right at home. We now offer a series of live, online group sessions with other pregnant women in the area to provide the information and guidance these women need. Topics of discussion include prenatal care, healthy eating and lifestyle habits, the effects of stress during pregnancy, preparation for childbirth, postpartum care, and general care for your baby.

Why Maternal Health Care Disparities Exist, and What to Do About Them

A lot of the racial and socioeconomic disparities in maternal health care have historical roots. In BIPOC communities, there is a deep mistrust when it comes to the health care system because of centuries-long trauma we've faced long before even my great-great grandmother's time. (Think: Henrietta Lacks and the Tuskegee syphilis experiment.) We're seeing the result of that trauma in real-time with hesitancy around the COVID-19 vaccine.

These communities are having a tough time trusting the safety of the vaccine because of the health care system's history of not being transparent and engaged with them. This hesitation is a direct result of the systemic racism, abuse, and neglect they've faced at the hands of the system that is now promising to do right by them.

As a community, we need to start talking about why prenatal care is so important. Babies of mothers who do not get prenatal care are three times (!) more likely to have a low birth weight and five times more likely to die than those born to mothers who do get care, according to the U.S. Department of Human Health and Services. The moms themselves are deprived of valuable care including monitoring potential health problems through physical exams, weight checks, blood and urine tests, and ultrasounds. They're also missing a crucial opportunity to discuss other potential issues such as physical and verbal abuse, HIV testing, and the effects alcohol, tobacco, and illicit drug use can have on their health. So this isn't something to be taken lightly.

In the same vein, it should also be common knowledge that you have to prepare your body before conceiving. It's not just about starting your prenatal vitamins and taking folic acid. You have to be healthy before taking on the burden of carrying a child. Do you have a good BMI? Are your hemoglobin A1C levels okay? How is your blood pressure? Are you aware of any pre-existing conditions? These are all questions every mother should be asking herself before deciding to conceive. These honest conversations are so important when it comes to women having healthy pregnancies and deliveries.

I've been trying to prepare and educate women about the above my entire adult life and will continue to do so for as long as I can. But this isn't something one person or one organization can solve. The system needs to change and the work that needs to go into can often feel insurmountable. Even on the most challenging of days, though, I simply try to remember that what might seem like a small step — i.e. having a prenatal consultation with one woman — can actually be a leap toward better health and wellness for all women.

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