A hand-painted sign that read “Black Mamas Matter!” leaned against a section of the exterior fence that separated Queens Hospital Center from 164th Street. One-by-one on October 17th, attendees approached a portable mic to demand an overhaul of New York’s maternal health care system.

This rally, and another held in May at Montefiore Medical Center in the Bronx, was in direct response to another Black woman’s maternal death at a city hospital. Since early March 2020, at least four Black women in New York City — Cordielle Street, Amber Isaac, Sha’asia Washington, and most recently Denise Williams — have made headlines by dying while giving birth or within the first year postpartum.

Both protests were organized by a new political coalition of birth workers and grieving family members determined to solve a crisis that predated and was compounded by COVID-19. Several studies have found over the years that Black New Yorkers were more than twice as likely as their white counterparts to have severe complications in childbirth and eight times as likely to die from pregnancy-associated causes.

In 2018, former Gov. Andrew Cuomo and Mayor Bill de Blasio each introduced comprehensive plans to address the problem. Their efforts followed decades of researchers, birthworkers and policy experts highlighting evidence-based solutions that could cut the maternal mortality rate by half.

Both plans contained policies and programs aimed at improving data collection and reporting, access to full spectrum doula and midwifery, and quality of hospital care. Unlike COVID-19 deaths, which both the city’s Department of Health and Mental Hygiene and New York State Department of Health (NYSDOH) release provisional data on in real-time, official maternal mortality and morbidity rates take years to publish.

But as the pandemic flooded city hospitals, many of the shortcomings of those initiatives that birth workers testified to in city and state oversight hearings emerged. Marginalized New Yorkers bore the consequences.

Myla Flores at the #WeHearYou #WeSeeYou Rally on May 8th, 2021.

During the pandemic, reports of restrictive hospital visitation policies and chaos in obstetric units citywide caused many New Yorkers to seek out-of-hospital maternity care. Other people who were pregnant left the city entirely. According to a May report from the Centers for Disease Control and Prevention, approximately 9% more white city residents went elsewhere to give birth in March and April 2020 than they had the previous year. Only 1-2% more Black birthing people did the same.

“We've been screaming to the rooftops about racism, how these institutions were never built for us and don't serve us now in 2021,” Emilie Rodriguez, a doula and founder of The Bridge Directory and Ashe Birthing Services.

The city’s Maternal Mortality and Morbidity Review Committee, a cornerstone of de Blasio’s $12.8 million plan, released its most recent report in April of this year. For the first time since its inception, the committee and its report qualified mental health disorders as a pregnancy-related cause of death within the first year postpartum. That’s significant because postpartum depressive symptoms affected about 15% of New York City births in 2018 according to the CDC and such circumstances played into Denise Williams’ death. The city’s findings also show slight improvements against both overall maternal mortality rates and racial disparities in 2017.

But this report’s release happened six months later than city law requires and its latest data hailed from 2017. Moreover, New Yorkers won’t be able to compare the 2017 numbers against information collected during the pandemic for several more years, and many birth workers fear the COVID-era data may not capture all of the deaths and near-misses they’ve witnessed these past 20 months. The city’s health department, which oversees the review committee, cites the complicated data collection process and privacy concerns as reasons for the lag time in reporting.

With a new governor in Albany and an incoming New York City mayor and City Council, birth justice advocates hope that their demands might finally be met and their work finally recognized.

Maternal Hospital Decline

In the meantime, public health experts and agencies are beginning to publish studies on the impact of COVID-19 on obstetric care, and they’re reviewing the challenges NYC birthing hospitals faced to prepare for future emergencies. A range of recent data reveal that short staffing, limited telehealth and forced separation of birthing person and baby were among the major trends in hospital-based maternity care over the last 20 months.

Improving Black-white disparities in quality of hospital care was one of the intended goals of de Blasio’s 2018 plan. The city’s health department and the Health + Hospitals Corporation (H+H), the nation’s largest public hospital network, have taken steps toward this goal.

The health department’s Maternal Health Quality Improvement Network — a cohort of 14 hospitals — shares webinars, toolkits and best practices for OB-GYNs. The network has convened virtually throughout the pandemic, per a city health department spokesperson. Some of the health department’s other notable projects include Standards for Respectful Care at Birth, a pamphlet informing birthing people of their rights, and a toolkit for OB-GYN departments on severe maternal morbidity. H+H took the lead on a $2.87 million obstetric emergency simulation training, which it expanded during the pandemic. The H+H press office highlights the over 1,000 staff who have received implicit bias training to-date as an improvement measure as well.

Without adequate funding, however, widespread data show that hospital quality of care declines. State cuts to New York City hospitals, inequitable distribution of Medicaid funding and decades of housing segregation have contributed to a maternal health care system that is both racially and economically segregated. In NYC, hospitals that serve majority-Black neighborhoods are typically public and chronically under-resourced, according to The New School's Center For New York City Affairs.

We let bad doctors keep working in public hospitals because when they cut our budget, we go into hiring freezes, and a bad doctor is better than no doctor at all.
Katy Cecen, a former SUNY Downstate nurse

At the height of the pandemic in March and April 2020, the Cuomo administration cut $138 million from H+H. An additional 18% reduction in indigent care support in this year’s fiscal budget would also disproportionately impact public hospitals that provide the majority of care to uninsured New Yorkers.

Katy Cecen, a former SUNY Downstate nurse who quit after witnessing preventable maternal deaths, described the consequences of state budget cuts: “We let bad doctors keep working in public hospitals because when they cut our budget, we go into hiring freezes, and a bad doctor is better than no doctor at all.”

A certified nurse midwife at a public hospital who asked not to be named out of fear of professional retaliation described her Labor & Delivery unit during the first COVID-19 surge: "So many of us got sick," she said. "You might have been on the floor where a third of the staff was out, which is really a lot." The nurse said there were many times where "we were discharging people within 12 hours" after giving birth. Normally, a birthing person stays in the hospital at least one full day after vaginal delivery and two days after a cesarean section birth.

At the height of the pandemic, many hospital-based midwives were deployed to pandemic response units or became sick with COVID-19 themselves. To supplement the shortage, Cuomo updated an early executive order in March 2020, to allow “midwives ... not registered in New York State” to practice here. But two certified nurse midwives at two separate H+H hospitals, who asked not to be named due to fears of retribution, said no out-of-state midwives were ever staffed at their places of employment.

Health + Hospitals, the city health department, the state health department, and the Greater New York Hospital Association, New York Presbyterian, Mount Sinai, and NYU Langone all declined WNYC/Gothamist’s request for specific staffing data. But Health + Hospitals’ press office said OB-GYN staff were reassigned to COVID-19 units across its 11 hospitals, but “no huge migration occurred.”

Montefiore Medical Center responded in a statement that its OB-GYN department remained “fully staffed and operational.”

Before his resignation in August, at the end of the last legislative session, Cuomo signed safe staffing legislation that requires hospital committees to develop staffing ratios for each department and make staffing data public. The law is a step toward improving hospital transparency that will enable birthing New Yorkers to make informed decisions about their care.

Doulas Left In Limbo

As demand grew for community-based obstetric care during the height of the pandemic’s first wave, New Yorkers faced obstacles to accessing doula and midwifery care and safe, out-of-hospital birthing facilities, according to birth workers and birthing people alike. Such trends are shown to worsen inequities in maternal health and birth outcomes.

Because of Cuomo’s restrictive hospital visitation policies from March to April 2020, doulas were barred from providing the in-person support shown to reduce medical interventions in childbirth associated with morbidity and mortality. Even after Cuomo expanded hospital visitation policies on April 29th, doulas like Emilie Rodriguez and her colleagues at Ashe Birthing Services were frequently kicked out of maternity wards because hospital staff didn’t view them as essential, they said. Without proof of essential worker status, doulas also feared breaking stay-at-home orders and NYPD-enforced curfews.

In response to doula-led advocacy, New York City Council Member Carlina Rivera intervened: “One thing we were successful in doing was making sure that doulas and midwives were classified as essential health care workers,” Rivera said. “I'm not sure why we have to fight to make that classification necessary. But it's certainly something that we're proud of.”

The pushback Council Member Rivera faced in getting doulas essential worker status is emblematic of a century-long conflict — often rooted in obstetric racism — between community-based birth workers and the medical establishment.

Omari Maynard and Children at an October 17th Rally in Queens.

One of the ongoing manifestations involves New York’s lack of Medicaid coverage for doula care. As of January 1st, neighboring New Jersey became one of three states to provide such coverage. New York does have a Medicaid Doula Pilot Program, which was a central point in Cuomo’s 2018 plan. The pilot was designed to be phased in by counties, starting with Erie in March 2019 and expanding to Kings one year later. According to Emilie Rodriguez and many community-based doulas in NYC, the pilot was created without adequate community input and, due to its stringent requirements on certification, hours, reporting, and inadequate reimbursement to providers, failed to ever get off the ground in Brooklyn. According to a state health department spokesperson, “a complete evaluation will be done” by February 2023, “which will help determine whether it is expanded” to other counties. No doulas in Brooklyn are currently enrolled.

What’s more, New York licensure policies restrict certified professional midwives, one of three types of midwifery designations, from practicing in the state. Research shows that states that better integrate midwifery into their health care systems have less mortality and morbidity. New York is one of 14 states without a professional midwife licensure process.

Cuomo’s updated executive order that allowed out-of-state midwives to practice legally in New York didn’t specifically extend to the hundreds of professional midwives already here. While the Birth Rights Bar Association’s interpretation of the update allowed for certified professional midwives licensed in other states to legally practice in New York during the emergency period, many professional midwives like Carmen Mojica didn’t want to put themselves in legal jeopardy. In his final years, Cuomo brought felony charges against three certified professional midwives for “unauthorized practice of a profession” throughout the state. Despite what many birth workers described as an urgent need for more midwives in their marginalized NYC communities, without explicit legal protections, certified professional midwives were too afraid to practice.

Instead of waiting for a new executive order, Mojica and other advocates worked with legislators to introduce a bill that allows professional midwives to practice in their communities. It’s currently laid over in committee. For Mojica, certified professional midwives “want to practice, but we also want to increase access.”

Looking Forward

In April 2020, New York’s COVID-19 Maternity Task Force released recommendations that enabled the state’s department of health to issue a revised certificate of need — as part of a pitch to expedite licenses for new midwifery-led birth centers. Cuomo celebrated the state’s approval of two temporary birth centers under the new guidelines, both of which were extensions of previously licensed facilities and physician-led.

This licensing process is still prohibitively time and cost burdensome for midwives. Staff at one of the locations had to stop attending births in March. And the New York State Department of Health confirmed that no additional birth centers have opened under the new guidelines.

On May 20th, after months of organizing with fellow community members, advocates succeeded in getting midwifery-led birth center legislation passed through the State Senate. The bill passed with unanimous support. But Cuomo never signed the legislation into law.

Signs from May 8th rally.

In a statement provided to WNYC/Gothamist, Gov. Hochul’s office said that it is “committed to addressing the maternal mortality crisis and closing disparities in pregnancy-related care, and we are exploring all options, including legislation, to deliver solutions.”

The spokesperson didn’t specify which legislative solutions the Governor supports, specifically.

Eric Adams, the Democratic candidate for New York City mayor, made his proposal for citywide access to full spectrum doula care a cornerstone of his health care policy platform during his primary race. New Yorkers will have to wait and see if he will follow through on this campaign promise if elected. His Republican opponent, Curtis Sliwa, hasn’t made any maternal health policy proposals public. WNYC/Gothamist has reached out to the Sliwa campaign to inquire but has yet to receive a response.