Inside the Fight to Bring Midwives Back to Massachusetts
Midwifery is often a cheaper and safer alternative for some childbirths, yet the state’s policies require midwives to jump through increasingly difficult hoops to practice.
![](https://www.thenation.com/wp-content/uploads/2024/07/Massachusetts-Midwives.jpg)
A student midwife taking a mother’s blood pressure.
(Jessica Rinaldi / Getty)
Emily Anesta ended her maternity leave in an unconventional way—testifying at the Massachusetts State House. With a panel of legislators stretched above her and a newborn in her lap, Anesta recounted the story of her home birth. This was her (and her baby’s) first time in the halls of the State House. Anesta was trained as an engineer, a far cry from the world of amendments and articles. But, for Anesta, the cause was worth the whiplash: she was campaigning for professional midwife licensure, a measure that would legitimize the work of midwives who do not work in hospitals.
“I knew… you know, that it was possible,” she says, “to come out of the experience of pregnancy and childbirth feeling strong and healthy and supported and powerful—that’s how I felt. And I knew that that was possible for many more people.”
Often called the “medical mecca” of America, Massachusetts boasts some of the best healthcare in the world. Despite this distinction, or perhaps because of it, alternative methods tend to get seriously slighted. Midwifery, a healthcare model which emphasizes low-intervention and individualized reproductive care, for example, is a cheaper and safer alternative for some childbirths. Yet, with Massachusetts’ over-medicalized and restrictive policies, midwives have to jump through increasingly difficult hoops to practice.
For the past century, lawmakers have blocked policies concerning birth center regulations, midwife licenses, and paying for midwife-led births through MassHealth. This has led many expecting parents to have no option but to give birth in a hospital. Tired of operating in the margins of the healthcare system, Massachusetts midwives have been fighting tirelessly for birth equity.
Her testimony and statehouse visit were Anesta’s self-proclaimed “baby steps” into birth equity advocacy. Three years after that experience, she cofounded the Bay State Birth Coalition, a consumer advocacy group that promotes midwifery and non-hospital birth options within Massachusetts. “The midwifery model of care is special,” she says. “[Midwifery] is a model that really centers the individual’s rights and bodily autonomy.”
Being a Bay State birth equity advocate is an uphill climb—Massachusetts has long been the center of the anti-midwifery movement. One hundred years before the movement became mainstream, Massachusetts physicians wanted to confine obstetric care to male doctors, arguing that women were unfit for the profession. In 1820, Boston physician John Ware wrote that “there is, perhaps, no place of equal size, in which [midwifery] has been so entirely confined to male practitioners, as [Boston].” By the early 20th century, Massachusetts had become one of the few states in America to explicitly criminalize midwifery, prosecuting midwives for attending home births.
The campaign to eliminate midwifery arose from a series of “interprofessional battles,” says Eugene Declercq, Professor of Community Health Sciences at Boston University. “As obstetrics rises as a profession, it becomes more and more difficult to sustain the level of respect [physicians] want to have if—quote unquote—“these women” can keep [practicing] it.”
Between 2011 and 2020, rates of severe maternal morbidity— instances where unexpected complications in labor and delivery significantly impact the birthing person’s health—doubled in the state of Massachusetts. Though Massachusetts is home to the best hospitals in the country, care is massively stratified across geographic, racial, and ethnic lines. The report, which the Department of Public Health released in July 2023, showed that rates of severe maternal morbidity for Black mothers are almost two and a half times higher than for their white counterparts, and almost one and a half times higher for Hispanic and Asian mothers.
In a healthcare system imbued with institutional racism and bias, white women have a better chance of being listened to, said Tiffany Vassell, a labor and delivery nurse and midwifery advocate. Black women are three times more likely to die from a pregnancy-related cause than their white counterparts and more likely to experience mistreatment during childbirth. At the same time, many studies have shown that midwife and non-hospital birth care is associated with fewer reports of discrimination amongst Black and brown birthing people.
During the birth of her first child, Vassell’s doctors kept checking her, giving her cervical exams—which she now reflects on as being unnecessary. Eventually, they recommended that she get a C-section, a surgical delivery of the baby. But Vassell was adamant about having a vaginal birth. “I had to be very aggressive and very clear about not wanting a C-section,” she said. Vassell’s story is not uncommon. Black women are pressured twice as often as white women to get C-sections, despite the fact that they have a lower chance of surviving them.
“That kind of started the fire within my gut with wanting to advocate for folks and their birthing experience,” she says. Now, she is a community advocate at the Neighborhood Birth Center, where she teaches workshops about birth centers and the midwifery model of care. The Neighborhood Birth Center has created new policies supporting midwives and has been attempting to establish a birth center with fair wages and reasonable work hours for midwives, relying on community support and legislative change to provide non-hospital options for residents in Eastern Massachusetts.
Many people of color in Massachusetts are unaware that there are non-hospital options available, Vassell explains. By introducing them to the midwife model, which prioritizes relationships and continuity of care, she hopes to improve health outcomes for her community. “I want to empower folks. I want folks to feel like when they go into a room with a clinician, that they feel heard and seen, and that they get the care that they know they deserve.”
Promoting the midwifery model of care has been historically difficult. Massachusetts is one of 14 states that do not provide licensure for professional midwives. Their practices are not explicitly illegal, but they are not regulated by the state either. The only midwives that operate in Massachusetts are nurse midwives, who have had extensive hospital training.
Rachel Blessington, the founder of the Worcester Community Midwifery, began as a labor and delivery nurse in a community hospital but found the work discouraging. “A hospital is trying to serve so many patients in a day, it feels like turning over a restaurant table,” she says. “That leads to a depersonalization of care.”
She went back to school to become a professional midwife, but professionalizing the field is enormously difficult. Professional midwives can’t bill most insurance companies, which means mothers who opt for a home birth can receive a bill that ranges from $3,000 to $9,000. Nor can professional midwives operate independently in birth centers—freestanding healthcare facilities that promote midwifery and low-intervention births, reduce racial disparities in pregnancy and lead to a decrease in surgical interventions during childbirth.
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“swipe left below to view more authors”Swipe →The Worcester Community Midwifery isn’t a birth center, but Blessington wants it to be. Freestanding birth centers provide a third option, apart from hospitals and home births, for people to give birth. They look more like houses, instead of hospitals, replacing the thin sheets of a hospital bed for full-size beds with comforters and large tubs. Giving birth at a birth center, Blessington says, “is a lot like a home birth at someone else’s place or a beautiful inn.” At a birth center, midwives are able to get to know their patients and spend more time with them. “The care outcomes are so much better because the style is more supportive.”
There are 400 accredited birth centers in the United States, but only one in Massachusetts—the Seven Sisters Midwifery in Northampton. The scarcity of centers had dire consequences on the growth of midwifery in the state. Most professional midwives can only get their training at an accredited birth center. “Without more birth centers, we don’t have places to train more midwives, especially ones that reflect our community,” Blessington says.
Ginny Miller, the current director of the Seven Sisters Midwifery tried to start a midwifery 40 years ago. “But my license did not allow me to work independently. I needed a supervising physician, and I couldn’t find anyone who would take that role on,” she says, referencing a regulation that required an ob-gyn to observe nurse-midwives. Once that law was overturned in 2012, it took eight years for Seven Sisters to build an entirely new building in compliance with antiquated and overly complex state regulations for birthing centers.
Though birth centers aim to demedicalize the birthing process, Massachusetts regulations make it impossible for a birth center to open without certain specifications—a birth center must have lighting, ventilation, and equipment fit for a surgical suite. Additionally, despite the 2012 law, every freestanding birth center must have a supervising obstetrician or gynecologist who oversees the facility. Though useful in a hospital, these regulations are unnecessary for the midwife’s scope of practice—low-intervention, low-risk births.
Opening a birth center may be hard, but keeping it open is even harder. Midwives get reimbursed 85 percent of what insurance companies pay doctors for the same care. This leads to a difficult financial deficit, though midwife-facilitated births are cheaper than hospital births. “If we don’t get either a change in reimbursement or some of the grants, we have about maybe four to five more months of payroll, we have to close,” Miller says.
This isn’t to say that there isn’t demand for non-hospital options. Seven Sisters hasn’t spent a single cent on advertising, according to Miller. “We can’t spend money on marketing, because we turn away too many people,” she says. The midwifery has a waiting list of three to five families a month.
After a sustained push by midwives and consumer advocates across the state, legislators began paying attention. This is the first time a bill that upheld professional midwife licensure has passed the Massachusetts House. The House also accepted key amendments, such as redefining what is considered a “low-risk” birth and providing equitable reimbursement for midwives—two major obstacles to non-hospital birth care in Massachusetts.
Different variations of the bill have been in the House for 40 years, blocked by medical doctors and their advocates trying to keep pregnancy and childbirth in the hospital. Getting the bill on the legislative agenda required a coordinated and careful effort—the advocates knocked on doors, implored legislators, conducted research, and pushed to get the bill on the desks of people that mattered. In late 2023, the Bay State Birth Coalition led a rally in front of the State House. Standing on a ledge in front of the towering black gates, activists spoke about the importance of midwives. Children held up signs proudly proclaiming: “A midwife caught me!”
Six months later on June 20, 2024, the same cheerful yet forceful sentiment—midwives save lives—went from outside of the gates to inside the House chamber. In an emotional House session, representatives shared their birth stories. “Midwifery was the norm for the segregated Black community,” Representative Brandy Fluker-Oakley said in her speech. She recounts the story of her own mother being born through a midwife-assisted vaginal birth, and the importance of midwives to her family. Representative Christopher Worrell told the House of his wife’s pregnancy loss. “[My wife’s] strength is a gift, but should not be required for any pregnant person,” he says. “Inaction on this blatant disregard for Black women’s health affects mothers and our babies.”
As the electronic ticker on the wall counted the votes, it soon became clear that not only would the maternal health bill pass, it would pass overwhelmingly. Though they needed to be quiet in the chambers, once outside of the room, excitement and tears resounded as the women hugged each other, relieved that their efforts had culminated in momentous change. Though there is still much work to be done (namely, passing the bill through the state Senate and the governor’s office), they could stop holding their breath. “We can’t even express our joy enough, because it has just truly been so much work to finally see that folks believe that birthing people deserve this kind of care,” Vassell says. “It has been just a labor of love.”
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![On Feb. 27, 2013, just a few hours after Solicitor General Donald Verrilli endeavored to protect the Voting Rights Act before the U.S. Supreme Court, he dropped by his boss’s office and told US Attorney General Eric Holder that arguments in the case, Shelby County v. Holder, had gone poorly. Verrilli warned Holder things might be worse than they feared: The Court intended to go after the entirety of preclearance, the VRA’s most crucial enforcement mechanism. Holder scarcely believed that could be possible. “The Voting Rights Act? Come on,” Holder said. But to the veteran solicitor general, recovering from the most brutal experience he’d ever had before the Court, the writing was on the wall. “I walked out of that courtroom certain that’s what was going to happen,” Verrilli told me. “I was never optimistic at all.” Verrilli had underestimated how meticulously John Roberts had planned for this moment. He never imagined that he’d be hit with such mendacious numbers and arguments in a sanctum he revered. And though his pessimism turned out to be abundantly justified, the dishonest reasoning behind Roberts’s decision – that the chief justice could just conjure a doctrine of his own creation and use it to eviscerate the most important civil rights legislation in the nation’s history – haunts the solicitor general to this day. It has remade American democracy as well. [dropcap]J[/dropcap]ohn Roberts had schemed for decades prior to this moment. Three years earlier, a test case known as Northwest Austin allowed Roberts to carefully plant the seeds for the challenge that foes of voting rights law mounted in Shelby County. A tiny municipal water board in a new Texas development posed a large constitutional question. The VRA’s preclearance regime required every locality in the state to -approve in advance any changes to voting procedures through the Department of Justice. Preclearance worked to right historical wrongs: The VRA mandated it in the handful of states and localities with the worst records of racial discrimination in elections; when Congress reauthorized the Voting Rights Act by near-unanimous margins in 2006, it relied on a record of ongoing modern chicanery stretching toward 14,000 pages, bearing eloquent testimony to the ongoing need for preclearance. Two lower federal courts had agreed that the utility district did not qualify for exemption from the VRA, and that preclearance itself remained a proportionate response by Congress. “The racial disparities revealed in the 2006 legislative record differ little from what Congress found in 1975,” wrote federal appeals Judge David Tatel. “In view of this extensive legislative record and the deference we owe Congress, we see no constitutional basis for rejecting Congress’s considered judgment.” Before Tatel wrote his decision, he read every page of the 2006 congressional report, and tracked the stories of canceled elections and last-second precinct switches across Mississippi, Louisiana and other covered states. He did so, he told me, because “I had no confidence that the Supreme Court would ever look at the record.” His fears were justified. On April 29, 2006, during the oral arguments over Northwest Austin, Roberts expressed impatience, and sounded as if he simply didn’t believe these challenges continued. “Well, that’s like the old elephant whistle. You know, I have this whistle to keep away the elephants,” he said, dismissively, as the defense pointed out the ongoing need for preclearance in the case. “There are no elephants, so it must work. “Obviously no one doubts the history here,” he added. “But at what point does that history stop justifying action with respect to some jurisdictions but not with respect to others . . . . When do they have to stop?” Neal Kaytal, then the principal deputy solicitor general, responded that since Congress had reauthorized the VRA for another 25 years, that date would be 2031. Roberts was unimpressed. “I mean, at some point it begins to look like the idea is that this is going to go on forever.” The court’s five conservatives wanted to move on, and several appeared ready to address the larger constitutional issues that would trigger a challenge the VRA, but didn’t have much beyond vibes to go on. So Roberts brokered a deal, and wrote an apparently unifying decision for a court that appeared deeply divided during oral arguments. Everybody won, sort of. The water district would be allowed to bail out of preclearance requirements. Other small entities were invited to apply for a reprieve. At the same time section 5—laying out the VRA’s preclearance regime— survived. The liberal justices bought time for Congress to potentially address the court’s impatience with the preclearance formula once more. “It wasn’t exactly a principled constitutional decision,” says Tatel, who had scoured the law to see if he could deliver a similar ruling that sanctioned a bailout for the water district, in part to keep the VRA away from the high court. But the law clearly didn’t allow it. (“It doesn’t work with the law. It’s not right,” he told me, “but that didn’t bother the court.”) “They made a deal,” says Edward Blum, who helped bring the challenge to the VRA, and would also mastermind the clutch of cases that led the court to end affirmative action in college admissions. Roberts seemed to have done the impossible, and he won praise from the media and court watchers for his measured and far-seeing “judicial statesmanship.” Liberals even claimed victory, crowing to The New Republic that they prevented the VRA from being struck down 5-4 by threatening some thunderous dissent that either led Justice Kennedy to get cold feet or the chief justice to back down. If the liberals wanted to celebrate an imaginary win, Roberts had no problem with that. The chief justice was busy digging a trench and setting a trap. Indeed, the liberal justices scarcely seemed to notice the actual language of the opinion that they signed onto. “Things have changed in the South,” Roberts declared, writing for the full court. The VRA, he wrote, “imposes current burdens and must be justified by current needs.” Roberts had conned the liberals into signing onto a broad indictment of the reasoning behind preclearance, aimed at a future case and a future decision. “The statute’s coverage formula is based on data that is now more than 35 years old,” Roberts argued, as though civil-right legislation had a sell-by date. “And there is considerable evidence that it fails to account for current political conditions.” Then Roberts made one additional stealth play that helped assure that the next challenge to the VRA would arise quickly and would be aided by the plaintiffs’ success in Northwest Austin. He made an observation known as dicta—a comment that might not be necessary to resolve a case or even be legally binding in the future, but that can be cited as a “persuasive authority.” This is where Roberts gave birth to the fiction of a “fundamental principle of equal sovereignty” among states. The trouble with the principle is that it does not exist. Roberts created it with an ellipsis and what can only be understood as deliberate misapplication of the law. Indeed, the Supreme Court had rejected this precise reading in a 1966 voting rights case that upheld the Act’s constitutionality, in the very sentence that Roberts later claimed said the opposite. How did he get away with turning up into down? He cut the clauses he didn’t like and called it law. Here is the actual decision from the case in question, Katzenbach v South Carolina: In acceptable legislative fashion, Congress chose to limit its attention to the geographic areas where immediate action seemed necessary . . . . The doctrine of the equality of States, invoked by South Carolina, does not bar this approach, for that doctrine applies only to the terms upon which States are admitted to the Union, and not to the remedies for local evils which have subsequently appeared. And here is what Roberts wrote: The Act also differentiates between the States, despite our historic tradition that all the States enjoy “equal sovereignty.” Distinctions can be justified in some cases. “The doctrine of the equality of States … does not bar … remedies for local evils which have subsequently appeared.” But a departure from the fundamental principle of equal sovereignty requires a showing that a statute’s disparate geographic coverage is sufficiently related to the problem that it targets. Before Roberts wrote this, there was no such principle—let alone a fundamental one. The cases that Roberts cites as authorities for the idea of equality among states actually concern the “equal footing doctrine,” which secures equality among newly admitted states. No fundamental principle of equality among states governs the Fifteenth Amendment, which explicitly hands Congress the power to enact appropriate legislation to ensure equal treatment of all voters within states. Liberal justices either didn’t notice the dicta or did not think that Roberts would be so brazen as to write it into law citing his own invented precedent the next time a preclearance case came before the court. They underestimated both his chutzpah and hubris. It would not be the first, or the last time. [dropcap]I[/dropcap]f Roberts weakened the VRA’s foundations in Northwest Austin, four years later, in Shelby County, he came with the bulldozer. The preclearance formula had become outdated and no longer considered “current conditions,” Roberts wrote, brushing aside the lengthy congressional record filled with modern-day examples. Singling out states for disparate treatment, he held, failed to accord each state its “equal sovereignty.” The decision appeared modest and suggested that the Court had little choice but to act. But the feigned modesty was pure misdirection. The Shelby County decision is a deeply radical one. It usurps powers the Constitution specifically awards Congress. It uses the fictional principle of equal sovereignty, cooked up by Roberts in 2009, as its basis. And it cites statistics that are factually wrong and misstate the U.S. census. In the wake of other draconian hard-right decisions, such Dobbs v. Jackson Women’s Health (2022), reversing the right to abortion, and Loper Bright Enterprises v. Raimondo (2024), striking down “chevron deference” and effectively undermining the authority of federal regulatory agencies, public confidence in the high court has plummeted. Large majorities of Americans see the justices as partisan proxies, viewing the law through whatever lens might create victories for their side. But even this disillusioned American majority may not suspect that the justices might just be making the law up as they go along—that their opinions carry footnotes and the force of law but stand on air. Nor do most Americans fully appreciate that five, and now six, of them can get away with this because they form a majority ideological bloc, accountable to no one. That’s the real story behind John Roberts’s opinion in Shelby County. The chief justice obliterated the most successful civil rights legislation this nation has ever seen not just on flimsy criteria but on none at all. “It’s made up,” the conservative judge and law professor Michael McConnell, a George W. Bush appointee, told NPR. “This is a principle of constitutional law of which I had never heard,” the conservative judge and legal scholar Richard Posner observed, “for the excellent reason that … there is no such principle.” “Yes, that’s right,” says Leah Litman, a law professor at the University of Michigan. “There are passing references to the idea of equal sovereignty. But if you pause and think about them for more than a second, it’s clear that [Roberts] made the doctrine into something that it just wasn’t.” Litman is the national authority on equal sovereignty. In 2016, she wrote a complete 67-page history of what Roberts called a “fundamental principle” and “historic tradition.” Her conclusion? Roberts manufactured it for his own purposes. It is, she writes, an “invented tradition”---invented by John Roberts, and then cited by John Roberts. What Roberts didn’t make up, he got wrong. Roberts based his reasoning that things had changed in the South on voter registration statistics that, to him, showed that Blacks and whites had reached something close to parity—and that in some states, Blacks had even surpassed whites. His opinion even included a chart ostensibly documenting this. In reality, though, Roberts had the statistics backward. They did not show what he said they did. In many cases, they showed the opposite. Roberts used the numbers from the Senate Judiciary Report—the one that Republicans generated after the VRA’s passage to plant a record for its judicial demise. And intentionally or otherwise, the GOP report got it wrong. Roberts and the committee overstated white registration numbers. The Roberts chart counted Hispanics as whites—even those who were not U.S. citizens and therefore ineligible to vote. That basic error threw off all the demographic comparisons. In Georgia, for example, Roberts claimed that Black registration had risen to 64.2 percent and white registration had fallen behind at 63.5. But without the Hispanic numbers, white registration grew to 68 percent. It’s an improvement from 1965. But it’s not an example of Black registration outpacing whites, as Roberts claimed. In Virginia, meanwhile, Roberts argued that the gap between whites and Blacks had narrowed to just 10 percent—when in reality, it was more than 14 percent. Roberts simply didn’t understand how the census reported race. The Bureau treats race and ethnicity differently. Hispanics are counted as an ethnicity, then usually included under white. The chief justice should have used the data for white-non-Hispanic. But that would not have given Roberts the result he wanted. When reporters asked the court to explain how he could have gotten something so basic so wrong, the chief justice declined to answer questions. The court “does not comment on its opinions,” said a spokesperson, “which speak for themselves.” [dropcap]“T[/dropcap]his was Congress’s decision to make,” solicitor general Verrilli told me—a power awarded explicitly by the Reconstruction amendments to the Constitution. Debo Adegbile, who defended the VRA before the court during both Shelby County and Northwest Austin, sees the long throughline of the Court’s resistance to the full sweep of those amendments. The court’s impatience with the past, its eagerness to declare the job complete and the nation whole, reminded him of the 1870s Cruikshank and Civil Rights Cases decisions that choked off Reconstruction and insisted Blacks must “cease to be the special favorites of the law” even as freed slaves carried scars of their bondage. “It’s just the continued resistance to the commitment to make the country whole and to be an inclusive democracy,” he told me. “And it’s being dressed up in sophisticated legal arguments. It’s not that we’re actually past anything. It’s that we are now at a point where we have the power to decide that we’re going to vary from the mission, create a situation where voters are exposed and . . . advantage the manipulations of state actors and local actors to impose barriers.” Holder still stammers in disbelief. “Okay, Mr. Chief Justice, you say that America has changed. OK. And what’s your basis for saying that, as opposed to Congress holding hearings, thousands of pages of testimony, hundreds of exhibits that say America has changed some, but not enough? You’re saying, ‘No, Congress, essentially you’re wrong.’ . . . OK. Then where were your researchers?” The former attorney general winces in horror when the case is referred to by its full name: Shelby County v Holder. He cites two days as the worst of his tenure: The day he accompanied President Barack Obama to console parents of children slain during the Sandy Hook massacre, and “the other one was to hear from the Supreme Court that the Voting Rights Act of 1965 was, in substantial ways, murdered.” “Nothing had changed in the South,” he told me. “The only thing that changed was the personnel on the U.S. Supreme Court.” Verrilli also replays this crushing defeat in his head, wondering if there was anything he could have done to guard the Voting Rights Act against implacable foes. “I wish I could tell you, David, that I have stopped doing that, but I have not. It haunts me to this day.” He slows and wipes his eyes. It’s clear he is fighting back tears, unsuccessfully. “I think all the time about what I might have done differently, because it was a devastating defeat and it had huge consequences. I take solace in the thought that I don’t think there’s anything I could have done differently. 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