Black Midwifery Shows a Way Forward for Abortion Care Despite Brutal Suppression

Photo: Sofia Rosenberg-Klainberg; Shakera C. Tems

Just after lunch on a Wednesday in June, 64 midwives and midwives-in-training were assembled in a classroom at the Columbia School of Nursing in Manhattan, performing abortions on dragonfruit. Tools were laid out on sterile sheets, just as they would have been if the patient were an actual person and not an exotic fruit. There were forceps to stabilize the “uterus,” a long plastic dilator to open the “cervix,” swabs, “iodine” (soy sauce), lidocaine syringes, and the manual vacuum aspirator, which is used to provide the abortion. The aspirator is made up of a thin plastic cannula that goes into the uterus, and at the other end, a fat plastic syringe, with a plunger that is pulled back to create suction. Seven trainers, both midwives and physicians, watched carefully as the trainee midwives worked in pairs, each taking a turn to hold the fruit steady while the other inserted the long cannula and sucked out the black-speckled pulp.

Michelle Drew, of Ubuntu Black Family Wellness Collective in Wilmington, Delaware, was the workshop’s lead instructor. A certified nurse-midwife with a doctorate in nursing practice, she circled the room to offer feedback on technique, then stopped to help a participant, taking their dragonfruit in one hand and the aspirator in the other. “A lot of times you see people going straight in,” she said, demonstrating how one might insert the cannula into the center of the uterus. “But when you are going in for the first time, go at an angle. So I’m going upward first. Gently, I feel the fundus,” she said, referring to the farthest wall of the uterus. “And then I’m pulling back,” she said, showing how to bring the cannula back towards the cervix. “Now I’m going to change my angle and go downward. Now I’m coming back, and then back in at 9 o’clock, and twisting, twisting. And if you do a good block with the lidocaine, you can relieve the uterine pain as well.” This methodical approach ensures an abortion is thorough, not leaving any pregnancy tissue behind.

Training of this kind is much harder to find than it should be. By New York state law, midwives are able to provide procedural and medication abortion, but they must have extra training for procedural abortion—both classroom instruction and practice, and then clinical training with real patients under the direction of a mentor. But most midwifery schools do not provide that training, partly because it is considered an advanced skill and so is not on the midwifery licensing exam, and partly because there are not enough abortion providers to be clinical mentors. What slots are available are often taken by OB-GYN residents, for whom it is a required part of training. Abortion is not accessible if there aren’t enough providers to train more providers—and that would be true even absent the other factors that make abortion care hard to come by, like restrictive laws, stigma, and suppression. It’s a vicious cycle.

“I have an obligation to serve your interests and your family’s interests, before I necessarily stick to rules that don’t make sense and that were actually intended to harm you.”

Here is what happens when there are not enough abortion providers: Drew told me the story of a woman named Precious. (“And she was. She was a wonderful young mother, just beautiful and sweet,” Drew said.) Precious acquired a heart condition during one of her pregnancies; she lost two-thirds of her heart function and was advised that she shouldn’t get pregnant again. But she did, and at first she felt fine. But by 14 weeks, it was clear that her heart was not going to make it through this pregnancy, and she needed to terminate. Drew, who at the time could not legally perform abortions, tried and tried to get her an appointment with a physician who could. But the few physicians who could do second trimester abortions were fully booked, partly because they were also providing so many low-risk first term abortions—exactly the kinds of abortions midwives could have safely performed. Drew called and called and Precious waited and waited, her heart function deteriorating. There were no appointments available before Precious crossed the 22 weeks and six days mark, after which Delaware prohibits abortion. She was not yet sick enough to qualify for an exception—at least not until 28 weeks, and by that time, the question became when to deliver instead of when to have an abortion. In the end, Precious gave birth to her baby at 32 weeks and then she died of heart failure. Drew went to her funeral.

“If you had advanced practice nurses [like midwives] and physician assistants who should have been available to do first trimester abortions in the office, then those physicians would’ve been available,” Drew said. “Women have died just because they couldn’t get an abortion before the state cut off, because there just weren’t enough abortion providers.”

Nineteen states and the District of Columbia allow some or all advanced practice clinicians—like midwives, nurse practitioners, and physician assistants—to provide procedural abortions. These clinicians generally do first trimester procedures, which account for more than 90 percent of abortions—and research has shown that first trimester abortions provided by those clinicians are just as safe as those provided by physicians. But none of that matters if midwives can’t get the training they need, and then can’t get the hospitals and clinics in which they work to let them provide care—because some administrators don’t even realize midwives can provide abortions or because the physicians who perform abortions don’t want midwives to join them. Both midwifery practice and abortion care have been suppressed, historically and more recently, by groups like the American Medical Association. (The AMA’s position is that abortion is both a human right and medical care. But whereas the AMA opposes the independent practice of medicine by non-physicians, other professional organizations do support qualified non-physicians providing abortion care, including the American College of Obstetricians and Gynecologists.) In fact, many people in the general public don’t realize how much midwives and other non-physician providers can do.

And that is where this conference, held by New York Midwives, came in: According to the organizers, it was the largest abortion training for midwives ever held. One goal was certainly to train these midwives, who came from New York, New Jersey, and Connecticut, to individually provide abortions. But there was also a systemic goal, to organize midwives to break down the many barriers to abortion care.

Drew was involved in changing the law in Delaware in 2022, which made it legal for advanced practice clinicians to perform abortions. She sees full spectrum sexual and reproductive care as part of her responsibility, as her grandmother and great-grandmother were both midwives who provided all the care their communities needed. She pointed out that, although abortion was legal in the United States until the mid-1800s, enslaved Black women were always prohibited from controlling their own fertility—nevertheless, enslaved midwives did provide abortion and contraception, even when they had to do it surreptitiously. “For Black midwives, this has always been a necessity and an act of resistance,” she said. “As a Black midwife, I had an obligation to continue to be part of that resistance to make sure that Black women had access to abortion the same way that my grandmother did, the same way that my great-grandmother did. And the way so many Black midwives did, at the risk of their own personal safety for 400 years.” In other words, Black midwives have always operated within brutal suppression—and Black midwifery knows ways of moving forward despite suppression. Drew grounded the workshop in that perspective, specific to Black American midwifery.

Helena Grant, a certified nurse-midwife and the president of New York Midwives, was at the workshop as an organizer. Like Drew, she situated abortion in the experiences of Black women. “The United States is the embarrassment of the industrialized world when it comes to maternal mortality and morbidity,” she said, pointing out that the rates are much worse for Black and Indigenous women but are bad across all races compared with other wealthy countries. She brought up how enslaved Black women were forced to go back to work in the fields immediately after birth. “What happened in the white patriarchal mind when white women wanted to work? Remember what Black women did. ‘Okay, white ladies, you want to work like these Black women? Drop that baby like it’s hot and you get back to work.’ When one group of women is allowed to suffer, eventually we’re all going to suffer.”

The morning of the conference, the airy, high-ceilinged conference room at Columbia was filled with midwives who wanted to step into the abortion provider gap. They were mostly (but not solely) cis women, a mix of races, ethnicities, and ages, wearing a lot of t-shirts printed with slogans like, “Probably thinking about abortion rights.” Drew, who had driven up from Wilmington the day before, was wearing a long, kente cloth blazer over a bright green dress. It was the summer solstice and almost exactly a year after the Dobbs decision that reversed Roe v. Wade—a year of abortion providers grappling with how to practice within the changed landscape. But Drew told the participants that day that they needed to look farther back: “You can’t correct a wrong without understanding it,” she said.

Drew described how community midwives, a majority of whom were Black, were nearly wiped out by the 1921 Sheppard-Towner Act, which sought to replace traditional community midwives with nurse-midwives, who were part of the medicalized system. (The vast majority of midwives working today, including those in this story, are certified nurse-midwives.) Drew described the historical shift this way: “Instead, we have these nurses who are from ‘good families,’ who are well behaved, who know their place, who will be enforcers of the restrictions on community-based midwives. And who will never, ever, ever try to overstep their boundaries with scope of practice or wanting to be unsupervised by physicians.”

Drew said that a different kind of midwifery remains necessary—a powerful, boundary-pushing midwifery that is resolutely centered on what patients need. She described her predicament before she was legally able to do abortions: She would routinely care for people with miscarriages, when the embryo or fetus was no longer viable, providing manual aspiration to clear the uterus. There was no difference in the procedure for abortion. So if someone wanted a first trimester abortion, she would, for instance, purposely not check for heart tones, because if she hadn’t heard heart tones, she could plausibly be managing a miscarriage. “I have an obligation to serve your interests and your family’s interests, before I necessarily stick to rules that don’t make sense and that were actually intended to harm you. So yes, when I didn’t have a choice, I broke the law, before I could get the law changed,” she said.

The workshop didn’t suggest that midwives should break the law. But Drew’s point was that being an effective midwife means being willing to fight, to organize, to be canny and cagey, to challenge rules that prevent people from getting the care they want.

“that’s why I talk about freedom, because if someone has to give you something that they can take away, you’re not free.”

Keeley McNamara, one of the trainers at the conference, had experience changing rules that didn’t make sense. While a midwife at NYC Health and Hospitals, which operates the public hospital system in New York City, she volunteered to work with the sole physician who ran the family planning clinic where abortions were done—and where McNamara provided manual vacuum aspiration for miscarriages—so that when the law was passed making midwife-provided abortion legal in New York in 2019, she would be trained and ready to go. She was shocked to find that even after it was legalized, she had to go through a nine-month process to get it added to her privileges at her hospital—she was the first one to push for it, and to get it. After she did, other midwives who work at NYC Health and Hospitals were able to add abortion to the privileges for midwives across the whole system, if they can get the training.

That afternoon, McNamara helped Tre Kwon, a registered nurse studying to be a midwife at SUNY Downstate, learn the procedure. Kwon found it was tricky to aspirate the dragonfruit. “This is really awkward right now, but the more I do it, I’ll become more comfortable. And this is actually the easiest part. It’s all these other contextual questions as well as the psychosocial complexity that each person brings that’s the hard part.”

Nicole DeNuccio, a practicing midwife who helped to organize the conference, said the hand skills involved in prepping the dragonfruit for the abortion—dilating the cervix, measuring the uterus—felt similar to placing an IUD, which she does routinely. She agreed that the procedure is perhaps the easiest part, and that the context swirling around abortion care is more difficult. “This is an essential part of our work as midwives,” she said. “But the barriers to acquire the training and find a setting in which you are able to practice are so immense. We’re still fighting to get hospital systems to value and hire midwives and enable us to practice to the full extent of our scope.” She said that it’s only been very recently, after the Dobbs decision and concerns about an influx of out-of-state patients, that administrators in her New York City hospital system have started to think about expanding the pool of abortion providers.

It was not just young midwives or student midwives who were eager for the opportunity to get training. Patricia O. Loftman, called “Mother Pat” by the other midwives, was there to speak about reproductive justice, but also to learn procedural abortion after a decades-long career directing the midwifery program at Harlem Hospital.

“I grew up watching women die from septic abortions. I don’t think anyone in this room has ever seen someone die from a septic abortion from back alley abortions. I’ve taken care of those women,” she said. “I never thought I would see the day when Roe v. Wade would disappear. I never did. Because my belief was that white women would protect their interests and in them protecting their interests, that would protect our interests.” She shook her head. “And that’s why I talk about freedom, because if someone has to give you something that they can take away, you’re not free.”

After the workshop, Mother Pat is considering coming out of retirement to provide abortion. “My goal is to become proficient. I’ve got a lot of free time,” she said.

Sarah DiGregorio is a health care journalist and the author of “Taking Care: The Story of Nursing and its Power to Change Our World” and “Early: An Intimate History of Premature Birth and What it Teaches Us About Being Human.”