RETURN TO TRADITION: Reviving cultural practices to improve birth outcomes

Michigan Maternal Mortality Surveillance (MMMS) numbers consistently indicate disproportionately higher maternal and infant death rates among the Native American population.

Between 2016 and 2020, pregnant and postpartum American Indian/Alaska Native women were twice as likely to die, when compared to white women. Those numbers were 142 to 72.2 per 100,000 live births, respectively. That data looked at all maternal deaths that occur during pregnancy, at delivery or within one year of pregnancy, and were not necessarily just associated with the pregnancies.

Regarding infant deaths, in 2023 the state of Michigan reported that, between 2019 and 2021, Native American infant deaths occurred at a rate of 14.1 per 1,000 live births, compared to a rate of 4.6 per 1,000 births among white infants.

As for the reasons, Michigan Public Health Institute officials cite a lack of accessible health care, financial resources, stable housing, and food security exacerbating challenges often faced by Indigenous families during pregnancy and often leading to higher risks of pregnancy-related complications and deaths.

But others close to Indigenous communities see another contributing factor: Traditional childbirth practices were outlawed years ago.

For centuries, Native American communities enlisted the family and friends, midwives, doulas and other birth workers, using oral traditions to pass down knowledge about the childbirth experience for the entire family. This support extended from before birth through delivery and postpartum.

By the 1920s, the Bureau of Indian Affairs disrupted these practices by relocating home and community births to hospitals. Then, in 1955, the inception of the federal Indian Health Service managed the care of Native Americans and many Indigenous traditions and ceremonies, including birth work, were eliminated.

Families were separated as Native American children were removed from their homes and placed in Indian boarding schools from the late 1860s until the 1960s. It was the U.S. government’s forced assimilation of Native American children into Western culture and it led to the suppression of Indigenous practices.

Traditional techniques

Not only are Indigenous families still impacted by that almost 100-year separation and disruption of their community, but Native Americans face increased risks when it comes to pregnancy, as reported by the National Institutes of Health in 2021. These risks include pre-existing medical conditions, reduced access to standard prenatal care and inaccurate estimation of gestational age, which can lead to post-term pregnancy complications.

“Having increased access to Indigenous birth workers is essential to reframe the significance of care for Native families due to the disconnection of solely Western-based care,” said Jamie Hubbard, owner and founder of Sacred Soul Doula and a former breastfeeding peer counselor for the Women, Infants, and Children program at the Berrien County Health Department.

In 2022, with funding from the Centers for Disease Control and Prevention, the MMMS program supported regional initiatives to address the maternal and infant birth outcome disparity.

One of their successes was to put an emphasis on better understanding the wraparound approach that’s applied in tribal communities.

Now, with the help of Indigenous doulas, birth workers, and lactation consultants, many Indigenous communities in Michigan are reviving these cultural practices around pregnancy and familyhood, including traditional birth methods, in an effort to reclaim birthing as a ceremony.

“Traditional birth workers provide a holistic approach to childbirth, acknowledging the transition from the spiritual to the physical world, incorporating the emotional, mental and spiritual components crucial to Indigenous health,” said Kelsey Wabanimkee, a certified doula who serves as the Community Doula TA Specialist and a current and active Michigan Doula Advisory Council member.

“Birth is an act of ceremony, and it encompasses all of that in honoring our next seven generations and the generations before us,” said Wabanimkee, who is a citizen of the Grand Traverse Band of Ottawa and Chippewa Indians.

As a leader in Anishinaabe family health, she said doulas are advocates for pregnant people, providing non-clinical emotional, physical, and informational support to them and their families.

“It’s important I think to recognize that Western medicine has traditionally not been open to thinking about accommodating … the practices that Indigenous people feel are important,” said Dr. Joe Santangelo, Munson Healthcare chief medical quality and safety officer. “And I think that’s been a problem throughout all of Western medicine.”

Santangelo said healthcare providers should work to address this issue.

Munson has approached it from a “listening standpoint,” he said. “With our indigenous communities … there’s just this history there of trauma and mistrust that I think we just should acknowledge. And I think we’re really working to.

“It’s a process that we need to continue to work on to make sure that we’re living up to our end of the bargain and being trustworthy partners to those families.”

One of the ways Munson is hoping to build this trust with Indigenous communities is by listening to what pregnant people want in their birth plans — and this may include doula services.

“When we think about doulas, we’re really looking for them to be a connection between the healthcare team and the birthing mom,” Santangelo said. “But they can be particularly important when there are nuances that our health care team may not be as aware of — like when we’re caring for Indigenous peoples.”

Growing interest

“The doula profession is known to improve outcomes for both the mother and the infant,” Dawn Shanafelt, director of maternal and infant health for the Michigan Department of Health and Human Services, said.

Doula-assisted mothers are four times less likely to have a baby with a low birth weight, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding, according to a 2013 study published in the Journal of Perinatal Education.

In addition to improved health outcomes, mothers often report a better birthing experience with a doula as well as more support after the birth, Shanafelt said.

And interest in doula care as a support during pregnancy may be growing in the United States and Michigan.

According to recent projections by research company Future Market Insights, this care is expected to grow by 6% each year in the next decade to 2033.

That growing interest is reported to be highest among Black, Indigenous and people of color (BIPOC) living in both rural and urban areas.

Hubbard and Wabanimkee are seeking to make doula care more accessible for these communities, which means certifying more doulas in or near the communities they hope to serve.

And the trends are pointing in that direction. In Michigan, the number of registered doulas is growing.

There were 285 doulas on the state registry in December 2023 and 637 registered doulas a year later, Laina Stebbins, associate public information officer with the MDHHS, said.

Across the state, Medicaid reimbursement counts, which include visits and labor services, show significant growth in doula usage over the past two years. The last quarter of 2023 averaged 96 doula reimbursement claims and, in 2024, the average was slightly more than 500 claims.

Santangelo said that Munson doesn’t track the number of births assisted by doulas, but said that “anecdotally, the demand is going up, which we think is great.”

Services today

Doula services are varied and depend on the provider. Some doulas specialize in the birthing process, and others focus on postpartum support.

In Michigan, most doulas are “full-scope or full-spectrum doulas” who provide care during pregnancy and postpartum, Shanafelt said.

The focus on postpartum care is a response to increased health risks that mothers face after giving birth.

According to the CDC, in 2020, one-third of pregnancy related deaths in the American Indian/Alaska Native community happened during or on the day of the birth, almost 17 percent died the first week, and 50 percent died between seven to 365 days after giving birth.

The same report identified COVID-19 and mental health issues as the most common reason for death, both accounting for 27.3 percent of fatalities. Heart conditions, hypertension, and embolism were the other listed causes. The report stated that 92 percent of these deaths were preventable.

In addition, doulas support the birthing person’s birth plan and advocate for them at doctor’s appointments, providing emotional support throughout the pregnancy, and some even help with chores.

Doulas play a special role in minority communities, advocating for customs and traditions, what MDHHS Medicaid Policy Specialist Lisa DiLernia called “the comfort measures” for the birthing individual, based on their culture.

“I would also add, too, that we know that the drivers of health inequities across the board — not just in the birthing experience, but in cancer and asthma and education, cardiac outcomes, just across the board — are the result of longstanding biases and racism and oppression,” DiLernia said. “And our systems have been built within that environment, so the systems can potentially perpetuate that.

“Having a team member to advocate for the birthing person can help balance any power imbalances that might occur in the delivery room.”

Hubbard said perinatal support should focus not only on the medical aspects of giving birth and being a parent but “also on our cultures and the reclaiming of Indigenous bodies, empowering and connecting the community.”

Hubbard advocates for the use of doulas as a whole, but especially for Indigenous women, because she knows the issues firsthand. She had complications during her first pregnancy that made the birth high-risk, so, with her second-born child, she was treated as high-risk.

“There were no explanations as to what was being done or why,” she said.

Hubbard said she felt that, during her experience in the hospital, she didn’t have a say in her delivery.

“It’s seen throughout statistics — and our own stories — that we are dehumanized, and there are cascades of unnecessary interventions and the pathologization of birthing naturally,” Hubbard said.

That experience inspired her to become certified in Indigenous birth work and lactation support to help marginalized people.

“It’s essential to reframe the significance of doula care for Native families due to the disconnection of solely Western-based care,” Wabanimkee said. “We are here to navigate spaces that connect the community.

“This is the Anishinaabe way.”