It was a chilly Wednesday in January when Kaylynn Begaye, six months pregnant, walked into the lobby of the Changing Woman Initiative, her mother, Christine, by her side. Begaye, 33, found herself in this clinic in Santa Fe, N.M., after one too many doctor visits in nearby Albuquerque had left her stressed out. Since giving birth to a son eight years ago, followed by a daughter five years later, Begaye, who is Diné (Navajo), said the treatment she endured during both of those deliveries left her dreading having to go through it all over again: getting separated from her newborns at birth without her consent, being rushed out of her hospital room while still in postpartum recovery, seeing her family treated poorly by a mostly white staff. The birth of her third baby would be different, she vowed. This time, it would be on her own terms.
The hostility that Begaye says she encountered from health workers is a common complaint among Indigenous women, although one that’s only beginning to be taken seriously. Those complaints align with stories that surfaced after news reports revealed the country’s disproportionate maternal mortality rate among Black women. According to one study, nearly a quarter of Native patients reported experiencing racial discrimination while visiting a doctor or health clinic, and 15 percent of those surveyed also said they avoided seeking health care altogether because they feared mistreatment. It’s easy, then, to understand why expectant Native mothers like Begaye are more likely to receive late or no prenatal care in New Mexico than non-Hispanic white mothers, a trend that matches national averages. But the data isn’t often interpreted this way.
“If you look at the data and you don’t know us, you make assumptions that we just don’t care, that we don’t go to appointments,” said Nicolle Gonzales, a Diné certified nurse-midwife and the founder of the Changing Woman Initiative, a birth center explicitly intended to serve the Indigenous community. “There are all these other issues. That’s why the data looks the way it does.”
There are many systemic factors that hinder Native American maternal health—problems arising from a legacy of neglect regarding Indigenous life. Today, many pregnant Native women lack insurance or struggle to find transportation to their medical appointments. Others face hurdles finding affordable housing or dealing with abusive partners and domestic violence.
Since 2015, Gonzales has been increasing the reach of her nonprofit health care collective, in part to respond to a broken health care system that has marginalized Native women. Although the Indian Health Service provides perinatal care at many of its 24 hospitals and 51 health centers across the country, a majority of these chronically underfunded facilities are overcrowded with patients, understaffed with medical experts, and, in the case of one facility last summer, unreliable. In August, dozens of Native mothers suddenly found themselves without health care when the Phoenix Indian Medical Center announced that it was closing. The obstetrics unit was being shuttered because of staffing problems, the IHS said. Some women were mere weeks away from giving birth. The center has since reopened, but only partially. The delivery ward remains closed, meaning expectant mothers are transferred to other facilities across Phoenix between their 32nd and 34th weeks of pregnancy. In response to this disservice, patients have mounted peaceful demonstrations, holding signs that read “Honor Native women.” They want answers from the IHS, but more than anything, they just want their treaty-protected health care back.
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Begaye, who is insured through Medicaid, struggled to find a new physician without a referral. “I felt like I had nowhere else to go,” she said. “I didn’t know any other doctor.” She didn’t want to rely on the IHS; it would require months of waiting for an appointment, she thought. The health care center where she had delivered before, the Lovelace Women’s Hospital in Albuquerque, was only slightly better, in her view. It was where she had given birth to her daughter two years earlier, but Begaye and her mother are still haunted by their harrowing experience. Immediately after delivery, Begaye’s newborn daughter was taken to the neonatal ICU, where she stayed for about 10 days; at one point the medical staff tried to administer a feeding tube, and Begaye intervened just in time. Both the separation and the attempted intubation were done without her consent. They told her her baby suffered from low blood sugar due to Begaye’s inability to produce enough breast milk. “Some of the comments they made were very rude,” she recalled. “Basically saying to me that if I breastfed my baby better, she would be out of the NICU by now.” She felt that she had done something wrong, and she believes that if she’d had more time to recover in the hospital, her lower stress levels might have improved her lactation.
There were other reasons to be concerned about Lovelace. Over the summer, reports surfaced about other Native mothers being separated from their newborns without their consent. In these cases, it had been part of the hospital’s Covid-19 policy, which had not been disclosed to patients. The mothers felt they had been targeted because of reports about the high rates of Native Americans testing positive for the coronavirus.
By her 19th week, the Diné mother said, she had struggled through six appointments with two new obstetricians for prenatal care; each time, she grew more unsettled. She booked her next appointment with Gonzales.
Tucked amid a maze of pink adobe-style medical offices, the Changing Woman Initiative doesn’t look or feel like a standard health clinic. The lobby’s plush couches flank a bookshelf featuring texts about reclaiming Indigenous motherhood. In the exam room, renderings of traditional birthing rites hang on the wall in soft natural light. At one point, Gonzales invited Begaye’s mother into the room to hear her grandchild’s healthy heartbeat. Resting back on the table, Begaye focused her gaze on her exposed belly. She looked calm. Later, she told me she felt more relaxed with Gonzales than she had with any of her doctors.
Begaye’s mother, Christine, was the one who recommended Gonzales to her daughter. Sitting in the lobby, she shared how her forced boarding school education, along with the indoctrination of Mennonite beliefs, had robbed her of some Indigenous practices imparted by her great-grandparents, who were traditional-medicine healers. Decades later, the most obvious symbol of such cultural disruption was the modest black bonnet tidily tacked atop her head.
Gonzales’s reassuring nature put both mother and daughter at ease. She arranged for the next appointment to be a visit at their home, where Begaye ultimately wants to give birth. As the pandemic continues to restrict families and loved ones from entering hospitals, another worry for Begaye is the thought of not having her mother and sisters by her side. “My team,” she called them.
Gonzales is one of a small but committed group of Indigenous midwives trained to provide modern, professional pregnancy and childbirth-related care in any setting. The added twist is that they also want to incorporate traditional knowledge into their practice, in the way of their ancestors. About 20 Indigenous midwives are believed to be practicing in the United States today, including Rhonda Lee Grantham (Cowlitz), Margaret David (Koyukon Athabascan), and Autumn Cavender-Wilson (Wahpetuwan Dakota). In 2019, a small delegation convened in Washington, D.C., for a congressional briefing about Native Americans and maternal health. The Changing Woman Initiative was among those submitting testimony.
When Gonzales launched the initiative nearly six years ago, her vision was simple: to create the first Indigenous traditional birthing center in the United States. Then as now, she draws much of her inspiration from Canada, where Indigenous midwifery is returning to communities where birthing rituals have been lost to cultural genocide. There, midwives are training an Indigenous midwifery workforce while convincing tribal communities that such culturally centered health care is critical.
Access to ancestral midwifery care is not always covered by Medicaid or other health insurance plans, an issue that Gonzales and her team are striving to correct. Meanwhile, as a nonprofit with a national board of directors, the Changing Woman Initiative secures grant funding year after year to assist mothers with little to no health care—a common obstacle for many Native Americans, despite access to the Indian Health Service. “We have a policy where we don’t turn any woman away,” Gonzales told me.
Historically, Black and brown women were forced to rely on midwives simply because the barriers to health care were so great. “The communities that had the traditional midwives were the ones that were the most oppressed,” said Marinah Farrell, the Changing Woman Initiative’s executive director. By the 1930s, midwifery had declined significantly under pressure from the American Board of Obstetrics and Gynecology, which pitted midwives against obstetricians. Soon thereafter, many states declared lay midwifery illegal.
As recently as 1940, traditional Navajo birthways were still commonplace, as chronicled in a rare report conducted by a Harvard anthropologist. The researchers documented the Navajo red rope birth, which performed an upright delivery, the “no sleep” songs sung during labor as a ceremony, and many other sacred practices culturally relevant to Diné beliefs, such as applying ashes in the birth space to frighten evil spirits away and spreading pollens to invite the baby into the world.
By the 1950s, midwifery was slowly being introduced in US medical institutions, and when the interest in it surged two decades later, the patients and providers involved generally didn’t include the Black or Indigenous practitioners who are credited with keeping midwifery alive. “The natural-birth movement of the ’70s was largely a white feminist movement,” said Farrell, who is Chicanx/Indigenous Mexican and a certified professional midwife.
Further damaging the relationship between Indigenous women and health care providers was the shameful practice of forced sterilization. Beginning in 1970, physicians working in the Indian Health Service carried out this permanent procedure to prevent pregnancies, an agenda initiated by an act of Congress. Over a six-year period, as many as a quarter of Native mothers were sterilized without their consent. Evidence suggests that this figure is probably an undercount.
Decades later, concerns about poor maternal health outcomes, especially among women of color, has finally reached Congress. On February 8, the founders of the Black Maternal Health Caucus reintroduced the Momnibus Act, which is focused on addressing the maternal health crisis among women of color. The package is a compilation of maternal health bills aimed at improving care, from perinatal access to investing in a workforce that is less white. Fewer than 10 percent of today’s certified nurse-midwives are practitioners of color. That figure is dramatically less for Indigenous midwives—by Gonzales’s account, as little as 1 percent.
In the wealthiest nation on Earth, mothers are dying at the highest rate in the developed world—and that rate is rising. Native Americans are more than twice as likely as other women to die from pregnancy-related causes. Gonzales had a harrowing experience with her Albuquerque delivery 20 years ago, when she nearly passed out. Diagnosed with preeclampsia, a hypertension disorder accounting for roughly 8 percent of maternal mortality deaths nationwide, she pushed out her firstborn amid extreme hemorrhaging and under duress. Doctors, she said, never let on how serious her postpartum injuries were: third-degree lacerations. Few family members attending the birth understood her suffering. In her pain, she said, she lost sight of preserving her placenta; she had planned to bury the birth organ in the traditional Diné way. Instead, the hospital staff tossed it aside as biowaste. These traumas forever changed her.
“I had no clue about birthing or traditional teachings at the time,” Gonzales said, and she quickly realized that few other Native women did. But like her, they were hungry for such knowledge. Remembering how it felt to be a young mother and be blamed for her delivery complications has influenced Gonzales in her counseling of other Indigenous women like Begaye. More than anything, she wants them to know that they are at the center of their birthing experience. “This isn’t just a career; it’s not just a job for me,” Gonzales said. “I see my role as a midwife in my community as a spiritual calling.”
Gonzales, now 41, grew up in the Four Corners region, in Waterflow, N.M., on the northeastern edge of the vast Navajo Nation. As we talked, we were standing in a room before a wall of glass jars filled with earth medicines like skullcap, marshmallow root, and alfalfa, herbs that relieve tensions and stressors unique to the mothering experience. Thinking of Begaye, I asked which one would be good for emotional healing. “It depends,” Gonzales replied. “If it’s for you, I’d advise you to check with your pueblo.” She was referencing my ties to nearby Laguna, the tribal community where I was raised. Gonzales is more likely than traditional midwives to turn to her patients for suggestions about cultural birth knowledge. She says it’s what differentiates this practice from the larger health care system—the intentional shift to provide services that more reflect the needs of Indigenous mothers. This philosophy keeps her grounded in the Changing Woman Initiative’s mission: to reclaim Indigenous motherhood in a way that her ancestors would approve of. “I do have elders I’m accountable to,” she said, by which she meant the medicine men and women who have been educating her.
There’s an added tension, she continued, in confronting an organized health care system that has steadily worked to erase these traditional birthways. In a recent essay, she referred to that system, which is so disruptive to traditional birthing practices and yet continues to regulate them, as a “public health irony—or cruel joke,” depending on one’s perspective. “Those of us who walk that path are constantly engaging tension on all fronts of reproductive and women’s health,” Gonzales said. “We experience the racism.” She then rattled off a series of the most common societal doubts she’s faced: Are we good enough? Are we smart enough? Do we know what we’re doing? Gonzales argues that the licensing process for midwives doesn’t consider culture, class, race, or access to the profession. Turning to tribal communities, she said that Indigenous midwifery also comes with a different set of questions. The toughest: “Are we so colonized that we can’t identify with our people anymore?” She added, “Having to work through that all the time to just try and provide care and services from a place of trust and respect—that’s a really hard thing.”
As Begaye and her mother made their way to the clinic door, they chatted with Gonzales. It turned out their families know each other, an unsurprising discovery in a vibrant kinship society like the Diné. The elder Begaye spoke mostly about the line of children whom Gonzales may have known as a girl—nearly a dozen sons and daughters who today span the ages of 14 to 40. Gonzales remembered a classmate, one of Christine Begaye’s eldest daughters. Both families had lived in Kirtland, N.M. Gonzales recalled how the old post office off Highway 64 had been converted into the Begayes’ home. The memory drew happy laughter that filled the room. For Gonzales, knowing this kind of familial backstory is an asset. Non-Indigenous midwives might not recognize how significant a loss it is when these family links are diminished.
Gonzales believes that bringing back birthing ceremonies could lead to a shift in how Native women are valued—women who today are victims of some of the highest rates of violent crime in the United States. “Some of our traditional teachings talk about women being the ‘fire keepers’ of their home,” Gonzales said. “In this way, maternal health is intersectional with Indigenous feminism. It isn’t just about birth and pregnancy. It’s our life. It’s our breath. It’s who we are in our community.” She added, “When we don’t support and protect women and remind them that they’re valuable, they’re important, that their life means something, this is where we run into these issues—us dying. Reclaiming birth is part of that process.”