Deep Care: A Qualitative Analysis of Black Community Midwifery

Deep Care: A Qualitative Analysis of Black Community Midwifery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Deep Care: A Qualitative Analysis of Black Community Midwifery Chinmayee Balachandra, Alejandro McGhee, Jay Mawuli, Keshia Pollack Porter, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8348707/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Black community midwifery has historically offered holistic, culturally grounded care for Black birthing people, yet remains marginalized within modern maternity systems. As disparities in Black maternal health outcomes persist, this qualitative study explored the values, services, and impacts of Black community midwifery across multiple U.S. regions. Methods: Using in-depth interviews, observations, and surveys with five midwives and 53 clients, family members, providers, and community stakeholders, we conducted inductive and deductive coding to identify core themes. Results: Analysis revealed 11 primary midwifery services—including family integration, social-emotional support, and dietary counseling—and five guiding values: deep care, patient autonomy, patient safety, lived experience, and spirituality. Deep care, a model that integrates clinical, emotional, cultural, and spiritual dimensions, emerged as the most persistent and defining value across participant narratives. Midwives were described as educators, advocates, and system navigators who fostered client autonomy while balancing clinical safety. Family and spiritual integration were critical components of care, particularly during birth and pregnancy loss. Clients reported greater self-efficacy, trust, and emotional wellbeing compared to conventional healthcare settings. Conclusion: Findings underscore Black community midwifery as a vital strategy for advancing maternal health equity. We recommend expanded investment in midwifery education, community-based birth infrastructure, and supportive policy reforms. Black community midwifery maternal health equity deep care Black maternal health qualitative research birth justice Contributions to the Literature Prior literature has neglected to highlight solutions to the United States’ Black maternal health crisis propelled by the Black community. This study provides valuable insights into Black community midwifery and community-based birth in the United States, a topic with limited existing research in this local context. Black community midwifery offers deep, holistic care that Black clients trust, desire and value. There is an urgent need for state and federal public health policies to support the midwifery workforce and community-based birth infrastructure. Background Midwifery, one of the world’s oldest professions, has held a storied importance for the Black community in the United States. Oral history denotes that the first traditional Black midwife–known later as a “grand midwife” likely arrived as early as 1619. 1 These midwives utilized a traditional skillset to serve enslaved Black women, poor white women and plantation mistresses in the Antebellum South. 2 For many rural Southern communities, these Black midwives were frequently the only source of pre-, post- and antenatal care and carried a vast wealth of knowledge and experience. 3 Importantly, the role of Black midwives extended far beyond labor and delivery. These midwives provided “care, nurturance and empowerment to children, other women and their families,” through spiritual community building, ancestral knowledge, and technical skill. 3 Prior to the 1940s, Black midwives attended up to 75% of births in their communities. 4 The advent of modern obstetrics brought an institutional deluge upon grand midwives, who were displaced from their practices over the next several decades. 4 , 5 Predominantly white, male obstetricians claimed that grand midwives were “ignorant, untrained, incompetent women,” and insisted on the safety and necessity of universal in-hospital birth. 5 Black midwifery was further marginalized by policy, e.g., the passage of the 1921 Shepphard-Towner Infancy and Protection Act required all midwives to obtain state licensure. 4 This new law imposed significant barriers to traditional Black midwifery overnight and paved the way for underrepresentation of modern Black midwives–who currently make up less than 7% of licensed midwives. 6 Today, while most midwives are certified nurse-midwives (CNMs) in hospital practice, community midwives remain a crucial support for Black birthing people seeking birth experiences out-of-hospital. Community midwives exist in many forms–certified professional midwives (CPMs), certified midwives (CMs), direct-entry midwives, and lay midwives. 7 In the midst of the Black perinatal health crisis and harm sustained within the medical system, Black birthing people and their families are increasingly seeking alternative childbirth experiences that prioritize emotional and physical safety and care. 8 , 9 This resurgence of Black midwifery has reanimated these traditions, situating midwives at the forefront of birth justice movements and community health innovation. We conducted a large scale in-depth qualitative study on Black community midwifery because community leaders and experts portray Black community midwifery as an effective strategy to address the Black maternal health crisis. Recent work on Black-led birth centers highlights this premise, framing these community models as justice-oriented responses to inequitable maternity care. 10 These models uplift community-driven values of safety, love, trust, and justice that operationalize a Black feminist ethic of care. 11 Our study explores how these contemporary Black midwives practice what we term “deep care.” Put simply, deep care is love. It allows for emotional, spiritual, political, and relational engagement with care recipients, prioritizes attentiveness and attunement to recipients, and takes responsibility for the recipients’ wellbeing. This concept builds upon and extends existing understandings of care as both survival strategy and moral response to systemic neglect. 12 It echoes a tradition that views care as a disciplined, political, and loving practice that sustains communities under oppression. 13 The study sought to describe the distinctive features of this care and to understand the type of support and services that Black midwives provide, their experience providing that care, and its impact on clients, midwives, family members, and the community. The study also explored the values that midwives carry into their practice and how those inform their work. Given that Black community midwifery is portrayed as an effective strategy to address the Black maternal health crisis, this paper seeks to describe the provision of care by Black midwives to Black clients and investigate how this care is provided. Specifically, the paper aims to: (1) examine the kinds of services that Black midwives provide and which services are most valued by clients; and (2) explore the values that midwives draw upon to deliver such care and how these values are reflected in their personal narratives. This study also focuses on the practice of deep care—a form of caregiving rooted in love defined by trust, commitment, and respect. 14 Deep care captures how Black midwives create conditions for safety and belonging through relationships that affirm the worth and humanity of birthing people. Methods This is a multiple case study of Black midwifery. Our methodological orientation was grounded in what Dána-Ain Davis describes as Black feminist ethnography- a research practice which pays close attention to gender, race, and power dynamics which deeply impact Black women and birthing peoples’ lives. 15 Following this framework, our study sought to be holistic, attending to all the people involved in the field of community midwifery and foregrounding the expertise of Black midwives themselves. foregrounded the knowledge of community midwives and allowed for their leadership in the telling of their stories by using open-ended interviewing techniques. We used open-ended interviewing techniques that allowed midwives to guide the telling of their own stories and did not restrict participation by credential or certification. Additionally, when we realized that low-income clients were missing from the clients’ voices present, we revised our sample to include them, reflecting an iterative and reflexive commitment consistent with Black feminist ethnographic principles. 15 Below, we first describe the overall design of the study and then we describe the design of the sub-study. Study oversight The study team established a group of five experts on Black maternal care to act as a study advisory group. The advisory group included an anthropologist researcher, a community midwife with more than thirty years of community-based practice, an obstetrician-gynecologist who chairs a rural hospital OB department and leads hospital-based programming to improve Black perinatal care, an artist, and a public health leader of a West coast program to address Black maternal mortality. Study sample and setting The study included Black community midwives as case participants and the midwives’ clients, clients’ families, collaborating providers, and community stakeholders as key informants. The study was conducted in states that we located in the south, northeast, Midwest, west, and pacific west of the United States. For anonymity, states are not named in this current study. To be eligible for inclusion in the study a midwives had to self-identify as Black or African American; be at least 18 years of age; be currently practicing within one of the include U.S. states; have a current midwifery license and certificate or was recognized as a traditional midwife; have practiced for at least five years; have clientele that were at least 40% Black; attend to at least 50% of their delivers in the home or in a birth center; had to be willing to provide 10–13 referrals who would serve as key informants; and consent to be audio recorded. Additionally, client key informants were eligible for inclusion in the study if they identified as Black or African American, had received midwifery care from the case midwife within the previous 3 years. Other key informants were eligible if they were generally knowledgeable of the midwife’s practice or the care a client’s key informant had received. All key informants had to consent to be audio-recorded. Recruiting of Participants, Screening of Midwife, Screening of Key Informants We utilized purposeful and snowball sampling for recruitment. First, we recruited midwives primarily through Sista Midwife Directory. Sista Midwife Directory is currently the largest online directory of Black birth workers. The study advisory group also assisted with recruitment. The research team used the eligibility criteria to screen midwives over videocalls. Key informants were identified during the midwife screening process, where each midwife was asked to provide name and contact information of up to 6 clients, 3 collaborating providers, and 4 community stakeholders. Collaborating providers included were defined as clinicians with whom the midwives provide care to clients in the community. They included midwifery students, massage therapists, imaging technicians, holistic care providers, and other service providers. Community stakeholders are described as individuals and organizations that provide direct or indirect support for the midwife’s work in their community. Data collection: Interviews, Observations, and Survey For this study, the team developed interview guides for midwife and key informant interviews (see Additional files 1 and 2). Midwife interviews were framed with open-ended questions and conducted in person by the principal investigator. These sessions were approximately 60–90 minutes with a total interview time of around 3 hours. The use of ethnographic interviewing techniques and minimized interview scripts was employed to build rapport and encourage a Midwife-led conversation. Observations were also made of midwife-client visits by the principal investigator, with one group visit observed, and multiple one-on-one visits observed. Key informant interviews were conducted using a semi-structured interview guide and conducted over zoom by all data collection team members. These interviews lasted for up to 2 hours. The research team conducted a survey of the client key informant immediately before the client’s interview using the MOR & MADM scale. The Mothers Autonomy in Decision Making (MADM) scale is utilized to rate the level of agency and autonomy that a person experiences when participating in decision making conversations with a maternity provider. 16 The MOR scale, Mothers on Respect index, asses respectful patient-provider interactions. These are both Likert scales. Developing codebook based on transcripts The interviews were first transcribed using Transcribe Me, a human-augmented automated transcription service. The research team read and memo-ed the transcripts iteratively and then defined an initial set of codes that were based on the interview guide. The codebook included deductive codes from the interview guide and inductive codes that emerged from the memos. Coding was conducted using Dedoose software. Each team member independently coded the same subset of transcripts, and then the analysis team reviewed and discussed their coding processes, decisions, and understanding of the code definitions. This occurred over the span of several months to achieve conceptual clarity on each code and build consensus and agreement between coders. Once the team reached consensus on coding, independent coding of all transcripts was completed by two members of the data analysis team. Upon completion of coding, the primary codes of Midwifery Services and Values of Midwives were selected for the purposes of this current study, and all sub-codes underneath these were also selected. In this study, Midwifery Services was defined as “the specific services that midwives provide to the clients in the community or in the hospital both one-on-one and within group settings.” In this study, Values of Midwives was defined as “the values that inform why these people became midwives and guide how they care for their clients.” The associated interview excerpts were extracted from Dedoose. We assessed the prevalence of certain codes across transcripts, as well as the persistence of codes within transcripts. Prevalence is defined as the frequency of codes across transcripts, and persistence is defined as the frequency and depth to which a code is discussed within a transcript. The excerpts were then closely reviewed by the research team, with regular analysis meetings and collaborative discussion about recurring themes, major points, and overarching patterns. Illustrative quotes from a variety of interviewees were selected to highlight these themes. Quotes are attributed to gendered pseudonyms in this paper. Results The age ranges of interviewees were from 26 to 84 years of age. Additionally, there was a diverse representation of religion and spirituality across the interviewees, with interviewees identifying with Catholic, Christian, Muslim, Hoodoo, Ifa, Mormon, Pentecostal, Baptist, and Land-Based faith traditions. Per the study criteria, all case midwives and clients identified as Black or African American, and other participant groups included white, multiracial, and Black interviewees. Below we first describe the midwifery services and values that interviewees described, and we discuss four major archetypes of midwifery care that emerged from our analysis. Midwifery Services We identified 11 distinct services provided by midwives. They included the following: educating and integrating the family unit, social emotional support, dietary and nutrition counseling, client advocacy, providing access to social networks, childbirth education, medical tests, physical activity and counseling, community education, spiritual support, and physical examination. Overall, the top three mentioned midwifery services were educating and integrating the family unit, social emotional support/counseling, and dietary and nutrition counseling. These services were also persistent within client interviews and were noted to be foundational to the client’s perception of what their midwives did for them over the course of their birth journey. Clients often spoke at length about this quality of the midwives’ care and provided personal, intimate details about how this impacted their experience. Values of Midwives We identified 4 primary values or principles that guide midwifery care–deep care, patient autonomy, patient safety, and spirituality. Interviewees report on midwifery values in 448 excerpts, with 147 from midwives, 126 from clients, 70 from collaborating providers, 36 from community stakeholders, 19 from midwife family, and 17 from client family. Deep care was mentioned within all participant groups and reflects the foundational value of midwifery care. Patient autonomy and patient safety were the next most prevalent values, with patient safety more persistent with midwife interviews, and patient autonomy within client narratives. Although spirituality was coded the least within Values of Midwives, it is notably persistent in midwife narratives. Further analysis revealed the following four distinct yet interrelated, overarching themes. Midwifery as a Conscious, Love-centered Clinical Practice Community midwives are intentional about the values—deep care, client autonomy, safety, and spirituality that they bring to their practice. Community midwives seemed willing to extend and perhaps stretch themselves in service of their clients’ health and wellbeing, deep care was frequently contrasted with the impersonal and often harmful experiences clients had within conventional healthcare systems. Several clients described midwifery care as loving, “feeling like family,” and the sense that midwives were genuinely invested in their emotional, physical, and spiritual wellbeing. Mariah (client), describing her experience of care: “It meant the world to me. It meant so much to me because I felt like I was treated like [myself]....She never rushed my appointment. So, of course, I'm a first-time mom. I had a million questions, and she would be like, "Okay. You want to have the last appointment? That way, I can have a longer time to talk to you?"...it meant so much to me. It made me more comfortable, made me more trustworthy towards her...I felt loved. And I know you don't feel that a lot by your provider, but literally, I felt loved by her.” Midwives emphasized the importance of patient autonomy. This was expressed through seeking client’s informed consent, shared decision-making, and acknowledging clients' cultural and emotional realities. Aiyana (client): “She makes you feel like, "You know your body, and I trust that you're doing everything in your power to make sure that you and your baby are okay." Mina (midwife): “When I'm done with my phone call. I always give people the option to seek care somewhere else. And sometimes, they decide their anxiety is a little too high for them to pursue home birth, and so they switch to OB care, which I support them in if that's how they feel.” Often, midwives considered both patient safety and autonomy, while understanding the importance of what clients desire when seeking their care. This was exemplified by one midwife, Sierra: (Sierra), when describing counseling a client and client family member: “So just really helping them identify when something truly is a problem versus when it's not. Because even [client partner] kept asking me like, "Is this normal? Is this normal? Is this normal?" I said, "It can be normal. We're going to watch all the other signs to make sure that nothing else is out of the normal range," right? So it's a matter of like, "I'm not going to tell you that this is normal because not everybody has this." But the thing that's going to indicate that this meconium is problematic is how is the baby dealing with it, right?” Midwives also recognized the healthy tension between patient safety and patient autonomy, and their efforts to balance their clinical expertise and recommendations with preserving the emotional safety that comes with listening to the needs of clients. Maya (midwife), discussing an outside midwifes’ case where a client refused hospital transfer: “Autonomy is an important piece... but I'm like, "We are supporting women that birth outside of the hospital. Is that not autonomy? Is that not enough autonomy?" In my head, I'm like, "She wants to hold her baby." This person wanted to hold their baby. It's not taking away her autonomy. It's giving her an opportunity to hold the child she's carried for nine months.” Informed consent was further reflected in practices described within the interviews, such as asking for permission before physical exams, individualized assessments for home birth eligibility, and careful postpartum practices like placental examination. Midwifery as Education, Advocacy, and System Navigation Participants described midwives as not only clinicians but also educators and advocates who prepare clients and families to navigate institutional systems. This included childbirth education, nutrition counseling, strategies for advocating within hospitals, and broader efforts to demystify midwifery through community education. Dietary and nutrition counseling was a prevalent service that participants noted, and a fundamental part of Black midwifery care. For example, midwives discussed their approaches to glucose testing and the risks of gestational diabetes, while also balancing client autonomy and intuition: Maya (midwife): “If a mom is going to tell me, "Hey, I feel this." I'm not going to take that for granted because women are so intuitive during their pregnancy... Maybe we can explore it a little bit more. Maybe she may not want a certain thing in her pregnancy...I'm okay with that...because some people do not want to do that glucose test. And I'm okay with that. But I also want you to recognize what are the issues with gestational diabetes. Do you really trust that your diet of what you're eating is low sugar and high protein, healthy fats, and things like that, fruits and vegetables?” Advocacy was both interpersonal and structural. In some cases, midwives directly communicated with healthcare providers to ensure clients had access to lab work, information, and resources. Some midwives even offered clients specific language and strategies to use in clinical encounters, supporting client advocacy in diverse settings. Deborah (client), describing counseling from a midwife about how her interactions with conventional medical establishment?: “ One thing that she particularly enforced is that if you don't fully understand something, you need to request a copy of the visit notes or the visit summary and you need to ask for a detailed explanation. You are due a detailed explanation. So you either get a follow-up consultation to discuss your additional questions, or you go over your summary and you decide what it is that you don't understand, and you revisit those topics, but you don't just let them go because that's where fear harbors is in the things that you don't understand.” The holistic approach of midwives was exemplified in their dietary, physical activity, and hydration counseling. The effectiveness of the delivery of physical activity messages was notably in the context of societal challenges pregnant clients face in implementing them, including cultural expectations and body image issues. Mia (collaborating provider), about a midwife’s care: “And it was a little hard because the mama had food aversions and wasn't really nourishing herself enough. But [midwife] convinced her to really commit to herself more, even when this mama didn't want to. This mama had so much fatigue. She was so sweet, but she just didn't want to get off the couch. She wasn't taking her vitamins that much. And [Midwife] lovingly - maybe it was a black woman to black woman thing - got her to do it. She got her to walk. She got her to take all of her vitamins, start drinking smoothies, just took better care of herself.” Midwifery as Cultural and Family Integration Practice Participant interviews identified the importance of culturally grounded midwifery that integrates family and community. Midwives were seen as bridges between clinical care and familial dynamics, helping to facilitate inclusive birthing environments while maintaining client comfort and emotional safety. Midwives were persistently cited by clients, client families, and collaborating providers as important bridges for fathers, and extending education, participation, and emotional safety to them as well. Samantha (client), about midwifery care she and her family received: “ [Midwife] made him feel empowered as a Black father by involving him in our visits, by allowing him to participate and be acknowledged and just overall a part of what was going on. He was a vital piece in all of that. She didn't just address me in my care and what I needed to do and exclude my spouse; she included him 100%. She told him ways that he could affirm me every day, ways that he could make sure I was following my diet [laughter]. Just giving us helpful advice on workouts and ways that I can involve my daughter, who was seven at the time. And it was just priceless because we had never experienced that before. With our first daughter, there were rare moments where he was even acknowledged, and he would be with me everywhere we went.” Another theme is the strength and tension of family involvement. For example, several participants described the challenges in family integration. One midwife described a case in which a mother's presence at a home birth created emotional distress for the birthing person, prompting a hospital transfer. Often, midwives were recognized by clients for their ability to create respectful spaces where family participation is encouraged without compromising client comfort and safety. These dynamics reflect the importance of intentional and inclusive planning and perhaps more importantly, emotional safety. Nathan (midwife’s husband), about the care she provides: “And so if there's issues between family members or siblings or children or spouses or whatever and that shit isn't handled, then that will cause issues at the home birth. And it can cause issues at the hospital birth too. But the hospital birth is designed for them to not really be communicating with each other anyways. You go stand over there or go in the other room, so it alleviates it in different ways. But [Midwife] approaches her care from a spiritual communal understanding of birth. This is a family experience. This is not an individual experience. It takes more than one person to create this life. It will take more than one person to raise and foster this life. You are all in this together. Everybody has different roles. And so one of her roles as a provider of midwifery care is just that, to make sure y'all are in this together.” Midwifery as a Spiritual, Ancestral and Emotional Practice Participants expressed that midwifery care is deeply spiritual and emotionally attuned. Social and emotional support was both a prevalent and persistent code within interviews. Spirituality was mainly mentioned by the midwives as a foundational pillar of why and how they do their work. Practices such as building birth altars, using herbs, and creating rituals were described alongside grief support after loss, affirming the midwives’ role in holding sacred space. Clients who had also experienced hospital care noted that this was unique about Black midwifery–that there was priority and attention given to the spiritual needs of birthing parents and families. Samantha (client): But the fact that [Midwife] came and was just like, "Is there any part of the birth where it's–" we may have a religious or a cultural ritual that we want to do when babies are born in our family that they need to be aware of. Is there anything we want to do with the placenta? Just being asked those questions before experiencing it meant a lot because I was like, "Wow. Actually, I didn't fully think about it, but now that you asked me, let me make sure. Is there something that I want to make sure I do to honor our family or our beliefs or anything like that?" And just the fact that she asked, that meant a lot to me.” Clients noted this type of care in the context of pregnancy loss as well, from miscarriage to previous choices to have an abortion. One client describes her midwife’s integration of spirituality to honor life and grief while having a home delivery of a stillborn. Tania (client): “Before [Midwife] left, she gave me this little satchel, and the satchel had flowers and herbs and everything. And she said, "When you have your baby, you can bury your baby with this." She gave me the idea of having a ceremony for my baby. So nobody had ever told us anything like that before. Nobody even gave it that type of sacredness. So I was careful to make sure that I captured it. I captured it. I wrote a letter to the baby. My husband got a chance to write a letter to the baby. We did our ceremony. We had the herbs and everything, and we buried our baby. So that was beautiful. Even though that ended in loss, it was so empowering to me because first of all, I did it by myself.” Midwives themselves called on deep wells of ancestral knowledge, intuition, and non-Western frameworks to provide care that bridges the spiritual and the clinical. In the excerpts, interviewees reflected on midwifery as an ancestral calling, with birth viewed as a sacred and divinely guided experience. Maya (midwife), describing the spirituality in her care: “So you might smell something and say, "Something smells like it's not right," right? And you're using these skills...to identify that there may be a problem that's coming up. Or you might feel something in a certain part of your body, and you're tuning into the things, and you're helping that mother tune into those things...What do you feel? What do you smell?...And then on top of that...it's how is this person connecting in a spiritual way. And it can be anything. It could be your God...it could be your ancestors. How is that individual connecting to their spiritual side? Because we're deeper beings. I mean, there's so much that makes us who we are. I think that's what I would say about traditional midwifery.” Sierra (midwife), describing being called to midwifery: “...Those of us that are called to do this work as midwives in a community-based setting, really, I feel like have been divinely appointed, right? Because it's almost like we're fighting for human rights to some degree…As I was ending the last part of my clinical training, and I was like, "Oh, my God. I don't think I can make it. This is too much. It's too hard." And then my grandmother called me one day out of the blue and was like, "[Midwife...] Did you know your great-great-grandmother was a grand midwife who practiced in the South?"...I knew immediately that was a sign from God telling me that I was doing exactly what I was supposed to do in this time in history right now. And that was just the field that I needed to get over the line, to complete it, to finish it.” Discussion Despite a growing body of literature on the history and resurgence of Black midwifery, there remains limited empirical research on its day-to-day practices. This study addresses that gap through a large-scale qualitative analysis of the services and values that define Black community midwifery in practice. We identified eleven services that Black community midwives provide and four primary values that guide their services. Additionally, educating and integrating the family unit, social emotional support/counseling, and dietary and nutrition counseling were the most reported services provided by midwives. Our study highlights Black community midwifery as a holistic, culturally grounded, and spiritually infused model of care. Across interviews, deep care emerged as a defining value, with clients describing familial, affirming, and attentive support that reflects a moral, emotional, and political commitment to sustaining life in the face of systemic harm. 12 , 17 , 18 These experiences align with literature showing greater perceived self-efficacy, autonomy, and respect in community birth settings compared to physician-led hospital births. 19 Midwives skillfully balanced patient autonomy and patient safety, emphasizing informed consent as an ongoing dialogue. They honored clients' bodily knowledge while maintaining clinical oversight, reflecting an ethical and clinically sound model of care. In the context of Black midwifery and otherwise, deep care is a politically rooted form of healing grounded in Black feminist thought. 13 , 20 . Furthermore, it represents an extension of longstanding theories of care as both relational and political practice. 12 , 17 This reframes care as a radical act of survival and communal resistance, rather than passive support. It becomes “a philosophy of survival in the face of literal and psychic death,” disrupting negative outcomes by centering collective well-being, spiritual connection, and ontological resistance to state-sanctioned neglect and violence. 13 Black midwives embody this through ancestral knowledge and attention to bodily, emotional, and spiritual wellness—echoing practices like storytelling, spiritual herbalism, and community ritual highlighted in Black feminist healing modalities. 20 In this sense, deep care reflects what has been described as “freedom work”—a practice that transforms care labor into a collective project of survival and liberation. 21 These acts of care reflect both clinical attentiveness and a sustained ethical stance, i.e., a refusal of disposability and an insistence on relational repair as central to health. 12 , 17 This form of care resists commodified, institutionalized models of wellness by reclaiming caregiving as sacred and culturally rooted, which is especially critical in a healthcare system that has violated and marginalized Black birthing people. Notably, the Black midwives interviewed in this study practiced a form of deep care that both includes and transcends clinical support and is shaped by Black feminist epistemologies that prioritize dignity, healing, and joy amid structural harm. This aligns with evidence that Black birthing people associate safety and well-being not only with clinical competence but with being cared for “from a place of love,” in spaces that affirm shared identity and trust. 9 Importantly, Black midwifery prioritizes love as a tool for promoting and protecting health and wellbeing. This love ethic, grounded in care, respect, and responsibility, reframes healing as a collectivist, justice-led act. 18 Through this, Black midwifery centers generative relationships that restore dignity, connection, and collective safety. Midwives were also described as educators and system navigators, preparing clients to advocate for themselves in institutional spaces and supporting holistic health through dietary and physical activity counseling. They communicated this information sensitively and with the client’s individual needs, resources, and emotional well-being in mind. This dimension of care further reflects midwives’ dual role as clinicians and community educators, translating love and responsibility into actionable guidance and advocacy. This is crucial, particularly given that pregnant individuals who experience body dysmorphia or negative body image are at risk of experiencing lower quality of life and worse pregnancy outcomes. 22 Midwives' ability to center relationships and tailor interventions was key to supporting behavior change in these contexts. The findings further underscore the cultural and family-centered nature of Black midwifery care. Midwives intentionally integrated fathers, children, and extended family into birthing processes while prioritizing emotional safety. Spiritual care was another cornerstone, with midwives drawing from ancestral practices to create sacred spaces around birth and loss. This is particularly notable given the historical marginalization of Black midwifery, which traces its roots to West African traditions disrupted by the rise of white midwifery and obstetrics. 18 Rituals around birth and loss, attention to spiritual connection, and references to ancestral calling situate Black community midwifery within broader traditions of sacred care work. This framing challenges dominant biomedical paradigms that often divorce birth from emotional, spiritual, and cultural contexts, reinforcing Black midwifery’s critical role in offering care that addresses the full humanity of Black birthing people. Implications Current approaches to the Black maternal health crisis often center hospital-based interventions. Our findings demonstrate that Black midwives play a critical role in improving outcomes through community-rooted, culturally grounded care. Models such as Beloved Birth Black Centering show that when care is co-designed with Black midwives, doulas, and families, it fosters trust, safety, and systemic accountability. 9 , 10 Policy efforts should expand Medicaid reimbursement for community midwifery and doula care, invest in Black-led birth centers, and support groups and wraparound care models. These strategies shift maternal health policy from reactive measures to structural repair, advancing a system where safety and justice are inseparable. Such investments align with current federal and state priorities under the Title V Maternal and Child Health Program and the Black Maternal Health Momnibus Act, which emphasize culturally congruent care, diversification of the perinatal workforce, and sustained funding for community-based maternal health organizations. 23 Strengths and Limitations This study is rooted in the personal narratives of Black community midwives and those most directly impacted by their care. Inherently, this is a strength as it offers nuanced and community-led insight—one that might be difficult to access from an institution-led lens. Additionally, this study surveyed and interviewed clients from several regions of the United States—all with different practice regulations. Interviewees were diverse, and this allows for a more inclusive picture of Black community midwifery. Finally, including key informants like collaborating providers, community stakeholders, and family members allows for a wrap-around view of midwifery care—and its ripple effects on family, community, and institutional structures. This study is somewhat limited by a lack of socioeconomic diversity—which is representative of a larger barrier to care. Typically, clients seeking community midwives or home birth must pay out of pocket, even if they are insured. The cost of a homebirth can be anywhere from 5500–8000 $ , limiting access to those who can afford it. 24 Many of the clients in this study paid out of pocket, which potentially limits the generalizability of these results to low-income birthing people. Additionally, this study utilized purposeful and snowball sampling. To participate in the study, clients had to be referred by the midwife. This might limit the study to clients who had positive relations with the midwife and potentially impacts the transferability of this study to larger populations. Of note, we interviewed a client who terminated her relationship with the midwife around labor. In that interview, the same values emerged. Future Directions Black community midwifery is a powerful avenue for addressing disparities in maternal health and could be critical to improving outcomes around physical and emotional safety for Black birthing people. Future studies should look towards the barriers that midwives face, as well as the resources they need to ensure this case is accessible for clients and sustainable for birth workers. Future research should also investigate the demand or preference for care attributes of the Black community midwifery in the general Black birthing population. Importantly, increasing the number of Black midwives through targeted recruitment and financial support in educational programs will be crucial. Additionally, investing in community-based birthing centers and expanding Medicaid coverage to include midwifery services are also vital steps toward creating a more inclusive and effective maternal healthcare system. Importantly, this study highlights the need for a care paradigm that supports Black birthing people, communities, and midwives—rather than one that lionizes them or overemphasizes their resilience in the face of structural oppression. Conclusions This study illuminates the vital role Black community midwifery plays in addressing the multifaceted crisis of Black maternal health. By centering "deep care"—a culturally grounded, emotionally attuned, and spiritually connected model of care—Black midwives provide affirmative support that goes far beyond clinical procedures. Their approach prioritizes education, autonomy, safety, advocacy, and family integration, all while drawing from ancestral knowledge and community wisdom. These values resonate deeply with Black birthing people seeking affirming, respectful, and holistic alternatives to institutionalized maternity care. The findings of this study affirm what generations have long known: Black midwifery is not only a practice of catching babies but one of catching families, communities, and histories. As the U.S. grapples with comparative poor over maternal health and serious disparities in maternal experience and outcomes, investing in Black midwifery is imperative. Sustained support for education, policy reform, Medicaid expansion, and culturally rooted birthing infrastructure can ensure that the future of maternal health is not only safer, but more just. Abbreviations CNM Certified nurse-midwife CPM Certified professional midwife CM Certified midwife MOR Mothers on Respect index MADM Mothers Autonomy in Decision Making scale Declarations Ethics Approval and Consent to Participate This study was approved by the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health (IRB #25161). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants were informed about the purpose of the study, assured of confidentiality, and provided written and verbal consent prior to participation. Participation was voluntary, and respondents could withdraw at any time without consequence. Consent for Publication Participants provided informed consent for the publication of de-identified interview excerpts and qualitative data. No identifying information is included in this manuscript, pseudonyms are used in lieu of names. Availability of Data and Materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Funding This work was supported by the Robert Wood Johnson Foundation (RWJF Grant #142141, Award ID# 80002). The funder had no role in the study design, data collection, analysis, interpretation, or manuscript preparation. Author’s Contributions CB led the drafting of the manuscript and contributed substantially to data analysis, interpretation, and critical revisions. AM, JM, KPP, DAD, and KF contributed to study conception and design, methodology, data collection, analysis, and manuscript revisions. DAD and KF provided project supervision. All authors reviewed and approved the final manuscript. Acknowledgements The authors extend deep gratitude to the Black midwives, clients, families, collaborating providers, and community stakeholders who generously shared their experiences and expertise. We thank Marjorie Paloma, Program Officer at the Robert Wood Johnson Foundation, for her support, and Ebonie Megibow for her contributions to codebook development. This work would not have been possible without the wisdom and leadership of Black midwives and the communities they serve. References Robinson SA. A historical development of midwifery in the black community: 1600–1940. J Nurse Midwifery . 1984;29(4):247-250. doi:10.1016/0091-2182(84)90128-9 Tunc TE. The Mistress, the Midwife, and the Medical Doctor: pregnancy and childbirth on the plantations of the antebellum American South, 1800–1860. Womens Hist Rev . 2010;19(3):395-419. doi:10.1080/09612025.2010.489348 Goode K, Katz Rothman B. African-American Midwifery, a History and a Lament. Am J Econ Sociol . 2017;76(1):65-94. doi:10.1111/ajes.12173 McCoy L. Black Midwifery in the US. Western Center on Law & Poverty. February 27, 2024. Accessed February 28, 2025. https://wclp.org/black-midwifery-in-the-us/ Thomasson MA, Treber J. From home to hospital: The evolution of childbirth in the United States, 1928–1940. Explor Econ Hist . 2008;45(1):76-99. doi:10.1016/j.eeh.2007.07.001 Mehra R, Alspaugh A, Joseph J, et al. Racism is a motivator and a barrier for people of color aspiring to become midwives in the United States. Health Serv Res . 2023;58(1):40-50. doi:10.1111/1475-6773.14037 Backes EP, National Academies of Sciences E, Division H and M, et al. Maternal and Newborn Care in the United States. In: Birth Settings in America: Outcomes, Quality, Access, and Choice . National Academies Press (US); 2020. Accessed February 28, 2025. https://www.ncbi.nlm.nih.gov/books/NBK555484/ Hoyert DL, Miniño, Arialdi M. National Vital Statistics Reports Volume 69, Number 2 January, 2020. Published online January 30, 2020. Karbeah J, Hardeman R, Katz N, Orionzi D, Kozhimannil KB. From a Place of Love: The Experiences of Birthing in a Black-Owned Culturally-Centered Community Birth Center. J Health Disparities Res Pract . 2022;15(2):47-60. De Ornelas M, Harley KG, Davis D, et al. A Community‐Centered and Antiracist Model of Whole‐Person Perinatal Care: Beloved Birth Black Centering. J Midwifery Womens Health . 2025;70(3):468-475. doi:10.1111/jmwh.13761 Welch L, Branch Canady R, Harmell C, White N, Snow C, Kane Low L. We Are Not Asking Permission to Save Our Own Lives: Black-Led Birth Centers to Address Health Inequities. J Perinat Neonatal Nurs . 2022;36(2):138-149. doi:10.1097/JPN.0000000000000649 Hobart HJK, Kneese T. Radical Care: Survival Strategies for Uncertain Times. Soc Text . 2020;38(1 (142)):1-16. doi:10.1215/01642472-7971067 Finch AK. Introduction: Black Feminism and the Practice of Care. Palimpsest . 2022;11(1):1-41. hooks bell 1952-2021. All about Love : New Visions . First edition. New York : William Morrow, [2000] ©2000; 2000. https://search.library.wisc.edu/catalog/999884519302121 Davis DA, Craven C. Feminist Ethnography: Thinking through Methodologies, Challenges, and Possibilities . Rowman & Littlefield; 2022. Accessed October 21, 2025. https://books.google.com/books?hl=en&lr=&id=3SlgEAAAQBAJ&oi=fnd&pg=PP1&dq=info:7b9aiT9Ox8QJ:scholar.google.com&ots=zDuhokCYLR&sig=d6wAoD6WtfRUwRYgSd3TyMm0wuA Vedam, Saraswati. The Mother’s Autonomy in Decision Making (MADM) scale: Patient-led development and psychometric testing of a new instrument to evaluate experience of maternity care | PLOS One. 2017. Accessed April 22, 2025. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0171804 Kittay EF. The Ethics of Care, Dependence, and Disability*. Ratio Juris . 2011;24(1):49-58. doi:10.1111/j.1467-9337.2010.00473.x Suárez-Baquero DFM, Joseph J, McLemore MR. Traditional Black Midwifery to Enhance Birth Justice. J Obstet Gynecol Neonatal Nurs . 2024;0(0). doi:10.1016/j.jogn.2024.07.003 Niles PM, Baumont M, Malhotra N, et al. Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter? Reprod Health . 2023;20(1):67. doi:10.1186/s12978-023-01584-1 Bogan EV, Harr ED. Health Equity Through Black Feminist Healing: A Narrative Review on the Contributions of Black Womxn to Integrative Medicine. Glob Adv Integr Med Health . 2025;14:27536130251332568. doi:10.1177/27536130251332568 Nadasen P. Care: The Highest Stage of Capitalism . Haymarket Books; 2023. Gibson AH, Zaikman Y, Rodriguez R, Bennett B. The effects of body dysmorphic disorder on women’s quality of life and body image at difference stages of pregnancy. BMC Pregnancy Childbirth . 2024;24(1):653. doi:10.1186/s12884-024-06857-6 The Momnibus Act | Black Maternal Health Caucus. March 7, 2020. Accessed October 21, 2025. http://blackmaternalhealthcaucus-underwood.house.gov/Momnibus Anderson DA, Gilkison GM. The Cost of Home Birth in the United States. Int J Environ Res Public Health . 2021;18(19):10361. doi:10.3390/ijerph181910361 Additional Declarations No competing interests reported. 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Literature","content":"\u003cul\u003e\n \u003cli\u003ePrior literature has neglected to highlight solutions to the United States’ Black maternal health crisis propelled by the Black community.\u003c/li\u003e\n \u003cli\u003eThis study provides valuable insights into Black community midwifery and community-based birth in the United States, a topic with limited existing research in this local context.\u003c/li\u003e\n \u003cli\u003eBlack community midwifery offers deep, holistic care that Black clients trust, desire and value.\u003c/li\u003e\n \u003cli\u003eThere is an urgent need for state and federal public health policies to support the midwifery workforce and community-based birth infrastructure.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eMidwifery, one of the world\u0026rsquo;s oldest professions, has held a storied importance for the Black community in the United States. Oral history denotes that the first traditional Black midwife\u0026ndash;known later as a \u0026ldquo;grand midwife\u0026rdquo; likely arrived as early as 1619.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e These midwives utilized a traditional skillset to serve enslaved Black women, poor white women and plantation mistresses in the Antebellum South.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e For many rural Southern communities, these Black midwives were frequently the only source of pre-, post- and antenatal care and carried a vast wealth of knowledge and experience.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Importantly, the role of Black midwives extended far beyond labor and delivery. These midwives provided \u0026ldquo;care, nurturance and empowerment to children, other women and their families,\u0026rdquo; through spiritual community building, ancestral knowledge, and technical skill.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrior to the 1940s, Black midwives attended up to 75% of births in their communities.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The advent of modern obstetrics brought an institutional deluge upon grand midwives, who were displaced from their practices over the next several decades.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Predominantly white, male obstetricians claimed that grand midwives were \u0026ldquo;ignorant, untrained, incompetent women,\u0026rdquo; and insisted on the safety and necessity of universal in-hospital birth.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Black midwifery was further marginalized by policy, e.g., the passage of the 1921 Shepphard-Towner Infancy and Protection Act required all midwives to obtain state licensure.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e This new law imposed significant barriers to traditional Black midwifery overnight and paved the way for underrepresentation of modern Black midwives\u0026ndash;who currently make up less than 7% of licensed midwives.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eToday, while most midwives are certified nurse-midwives (CNMs) in hospital practice, community midwives remain a crucial support for Black birthing people seeking birth experiences out-of-hospital. Community midwives exist in many forms\u0026ndash;certified professional midwives (CPMs), certified midwives (CMs), direct-entry midwives, and lay midwives.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In the midst of the Black perinatal health crisis and harm sustained within the medical system, Black birthing people and their families are increasingly seeking alternative childbirth experiences that prioritize emotional and physical safety and care.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e This resurgence of Black midwifery has reanimated these traditions, situating midwives at the forefront of birth justice movements and community health innovation.\u003c/p\u003e \u003cp\u003eWe conducted a large scale in-depth qualitative study on Black community midwifery because community leaders and experts portray Black community midwifery as an effective strategy to address the Black maternal health crisis. Recent work on Black-led birth centers highlights this premise, framing these community models as justice-oriented responses to inequitable maternity care.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e These models uplift community-driven values of safety, love, trust, and justice that operationalize a Black feminist ethic of care.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Our study explores how these contemporary Black midwives practice what we term \u0026ldquo;deep care.\u0026rdquo; Put simply, deep care is love. It allows for emotional, spiritual, political, and relational engagement with care recipients, prioritizes attentiveness and attunement to recipients, and takes responsibility for the recipients\u0026rsquo; wellbeing.\u003c/p\u003e \u003cp\u003eThis concept builds upon and extends existing understandings of care as both survival strategy and moral response to systemic neglect.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e It echoes a tradition that views care as a disciplined, political, and loving practice that sustains communities under oppression.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The study sought to describe the distinctive features of this care and to understand the type of support and services that Black midwives provide, their experience providing that care, and its impact on clients, midwives, family members, and the community. The study also explored the values that midwives carry into their practice and how those inform their work.\u003c/p\u003e \u003cp\u003eGiven that Black community midwifery is portrayed as an effective strategy to address the Black maternal health crisis, this paper seeks to describe the provision of care by Black midwives to Black clients and investigate how this care is provided. Specifically, the paper aims to: (1) examine the kinds of services that Black midwives provide and which services are most valued by clients; and (2) explore the values that midwives draw upon to deliver such care and how these values are reflected in their personal narratives. This study also focuses on the practice of deep care\u0026mdash;a form of caregiving rooted in love defined by trust, commitment, and respect.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Deep care captures how Black midwives create conditions for safety and belonging through relationships that affirm the worth and humanity of birthing people.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a multiple case study of Black midwifery. Our methodological orientation was grounded in what D\u0026aacute;na-Ain Davis describes as \u003cem\u003eBlack feminist ethnography-\u003c/em\u003e a research practice which pays close attention to gender, race, and power dynamics which deeply impact Black women and birthing peoples\u0026rsquo; lives.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Following this framework, our study sought to be holistic, attending to all the people involved in the field of community midwifery and foregrounding the expertise of Black midwives themselves. foregrounded the knowledge of community midwives and allowed for their leadership in the telling of their stories by using open-ended interviewing techniques. We used open-ended interviewing techniques that allowed midwives to guide the telling of their own stories and did not restrict participation by credential or certification. Additionally, when we realized that low-income clients were missing from the clients\u0026rsquo; voices present, we revised our sample to include them, reflecting an iterative and reflexive commitment consistent with Black feminist ethnographic principles.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Below, we first describe the overall design of the study and then we describe the design of the sub-study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy oversight\u003c/h2\u003e \u003cp\u003eThe study team established a group of five experts on Black maternal care to act as a study advisory group. The advisory group included an anthropologist researcher, a community midwife with more than thirty years of community-based practice, an obstetrician-gynecologist who chairs a rural hospital OB department and leads hospital-based programming to improve Black perinatal care, an artist, and a public health leader of a West coast program to address Black maternal mortality.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy sample and setting\u003c/h3\u003e\n\u003cp\u003e The study included Black community midwives as case participants and the midwives\u0026rsquo; clients, clients\u0026rsquo; families, collaborating providers, and community stakeholders as key informants. The study was conducted in states that we located in the south, northeast, Midwest, west, and pacific west of the United States. For anonymity, states are not named in this current study. To be eligible for inclusion in the study a midwives had to self-identify as Black or African American; be at least 18 years of age; be currently practicing within one of the include U.S. states; have a current midwifery license and certificate or was recognized as a traditional midwife; have practiced for at least five years; have clientele that were at least 40% Black; attend to at least 50% of their delivers in the home or in a birth center; had to be willing to provide 10\u0026ndash;13 referrals who would serve as key informants; and consent to be audio recorded.\u003c/p\u003e \u003cp\u003eAdditionally, client key informants were eligible for inclusion in the study if they identified as Black or African American, had received midwifery care from the case midwife within the previous 3 years. Other key informants were eligible if they were generally knowledgeable of the midwife\u0026rsquo;s practice or the care a client\u0026rsquo;s key informant had received. All key informants had to consent to be audio-recorded.\u003c/p\u003e\n\u003ch3\u003eRecruiting of Participants, Screening of Midwife, Screening of Key Informants\u003c/h3\u003e\n\u003cp\u003eWe utilized purposeful and snowball sampling for recruitment. First, we recruited midwives primarily through Sista Midwife Directory. Sista Midwife Directory is currently the largest online directory of Black birth workers. The study advisory group also assisted with recruitment. The research team used the eligibility criteria to screen midwives over videocalls.\u003c/p\u003e \u003cp\u003eKey informants were identified during the midwife screening process, where each midwife was asked to provide name and contact information of up to 6 clients, 3 collaborating providers, and 4 community stakeholders. Collaborating providers included were defined as clinicians with whom the midwives provide care to clients in the community. They included midwifery students, massage therapists, imaging technicians, holistic care providers, and other service providers. Community stakeholders are described as individuals and organizations that provide direct or indirect support for the midwife\u0026rsquo;s work in their community.\u003c/p\u003e\n\u003ch3\u003eData collection: Interviews, Observations, and Survey\u003c/h3\u003e\n\u003cp\u003eFor this study, the team developed interview guides for midwife and key informant interviews (see Additional files 1 and 2). Midwife interviews were framed with open-ended questions and conducted in person by the principal investigator. These sessions were approximately 60\u0026ndash;90 minutes with a total interview time of around 3 hours. The use of ethnographic interviewing techniques and minimized interview scripts was employed to build rapport and encourage a Midwife-led conversation. Observations were also made of midwife-client visits by the principal investigator, with one group visit observed, and multiple one-on-one visits observed. Key informant interviews were conducted using a semi-structured interview guide and conducted over zoom by all data collection team members. These interviews lasted for up to 2 hours.\u003c/p\u003e \u003cp\u003eThe research team conducted a survey of the client key informant immediately before the client\u0026rsquo;s interview using the MOR \u0026amp; MADM scale. The Mothers Autonomy in Decision Making (MADM) scale is utilized to rate the level of agency and autonomy that a person experiences when participating in decision making conversations with a maternity provider.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e The MOR scale, Mothers on Respect index, asses respectful patient-provider interactions. These are both Likert scales.\u003c/p\u003e\n\u003ch3\u003eDeveloping codebook based on transcripts\u003c/h3\u003e\n\u003cp\u003eThe interviews were first transcribed using Transcribe Me, a human-augmented automated transcription service. The research team read and memo-ed the transcripts iteratively and then defined an initial set of codes that were based on the interview guide. The codebook included deductive codes from the interview guide and inductive codes that emerged from the memos. Coding was conducted using Dedoose software. Each team member independently coded the same subset of transcripts, and then the analysis team reviewed and discussed their coding processes, decisions, and understanding of the code definitions. This occurred over the span of several months to achieve conceptual clarity on each code and build consensus and agreement between coders. Once the team reached consensus on coding, independent coding of all transcripts was completed by two members of the data analysis team.\u003c/p\u003e \u003cp\u003eUpon completion of coding, the primary codes of Midwifery Services and Values of Midwives were selected for the purposes of this current study, and all sub-codes underneath these were also selected. In this study, Midwifery Services was defined as \u0026ldquo;the specific services that midwives provide to the clients in the community or in the hospital both one-on-one and within group settings.\u0026rdquo; In this study, Values of Midwives was defined as \u0026ldquo;the values that inform why these people became midwives and guide how they care for their clients.\u0026rdquo; The associated interview excerpts were extracted from Dedoose. We assessed the prevalence of certain codes across transcripts, as well as the persistence of codes within transcripts. Prevalence is defined as the frequency of codes across transcripts, and persistence is defined as the frequency and depth to which a code is discussed within a transcript. The excerpts were then closely reviewed by the research team, with regular analysis meetings and collaborative discussion about recurring themes, major points, and overarching patterns. Illustrative quotes from a variety of interviewees were selected to highlight these themes. Quotes are attributed to gendered pseudonyms in this paper.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe age ranges of interviewees were from 26 to 84 years of age. Additionally, there was a diverse representation of religion and spirituality across the interviewees, with interviewees identifying with Catholic, Christian, Muslim, Hoodoo, Ifa, Mormon, Pentecostal, Baptist, and Land-Based faith traditions. Per the study criteria, all case midwives and clients identified as Black or African American, and other participant groups included white, multiracial, and Black interviewees. Below we first describe the midwifery services and values that interviewees described, and we discuss four major archetypes of midwifery care that emerged from our analysis.\u003c/p\u003e\n\u003ch3\u003eMidwifery Services\u003c/h3\u003e\n\u003cp\u003eWe identified 11 distinct services provided by midwives. They included the following: educating and integrating the family unit, social emotional support, dietary and nutrition counseling, client advocacy, providing access to social networks, childbirth education, medical tests, physical activity and counseling, community education, spiritual support, and physical examination. Overall, the top three mentioned midwifery services were educating and integrating the family unit, social emotional support/counseling, and dietary and nutrition counseling. These services were also persistent within client interviews and were noted to be foundational to the client\u0026rsquo;s perception of what their midwives did for them over the course of their birth journey. Clients often spoke at length about this quality of the midwives\u0026rsquo; care and provided personal, intimate details about how this impacted their experience.\u003c/p\u003e\n\u003ch3\u003eValues of Midwives\u003c/h3\u003e\n\u003cp\u003eWe identified 4 primary values or principles that guide midwifery care\u0026ndash;deep care, patient autonomy, patient safety, and spirituality. Interviewees report on midwifery values in 448 excerpts, with 147 from midwives, 126 from clients, 70 from collaborating providers, 36 from community stakeholders, 19 from midwife family, and 17 from client family. Deep care was mentioned within all participant groups and reflects the foundational value of midwifery care. Patient autonomy and patient safety were the next most prevalent values, with patient safety more persistent with midwife interviews, and patient autonomy within client narratives. Although spirituality was coded the least within Values of Midwives, it is notably persistent in midwife narratives. Further analysis revealed the following four distinct yet interrelated, overarching themes.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMidwifery as a Conscious, Love-centered Clinical Practice\u003c/h2\u003e \u003cp\u003eCommunity midwives are intentional about the values\u0026mdash;deep care, client autonomy, safety, and spirituality that they bring to their practice. Community midwives seemed willing to extend and perhaps stretch themselves in service of their clients\u0026rsquo; health and wellbeing, deep care was frequently contrasted with the impersonal and often harmful experiences clients had within conventional healthcare systems. Several clients described midwifery care as loving, \u0026ldquo;feeling like family,\u0026rdquo; and the sense that midwives were genuinely invested in their emotional, physical, and spiritual wellbeing.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMariah (client), describing her experience of care: \u003cem\u003e\u0026ldquo;It meant the world to me. It meant so much to me because I felt like I was treated like [myself]....She never rushed my appointment. So, of course, I'm a first-time mom. I had a million questions, and she would be like, \"Okay. You want to have the last appointment? That way, I can have a longer time to talk to you?\"...it meant so much to me. It made me more comfortable, made me more trustworthy towards her...I felt loved. And I know you don't feel that a lot by your provider, but literally, I felt loved by her.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMidwives emphasized the importance of patient autonomy. This was expressed through seeking client\u0026rsquo;s informed consent, shared decision-making, and acknowledging clients' cultural and emotional realities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAiyana (client): \u003cem\u003e\u0026ldquo;She makes you feel like, \"You know your body, and I trust that you're doing everything in your power to make sure that you and your baby are okay.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMina (midwife): \u003cem\u003e\u0026ldquo;When I'm done with my phone call. I always give people the option to seek care somewhere else. And sometimes, they decide their anxiety is a little too high for them to pursue home birth, and so they switch to OB care, which I support them in if that's how they feel.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOften, midwives considered both patient safety and autonomy, while understanding the importance of what clients desire when seeking their care. This was exemplified by one midwife, Sierra:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e(Sierra), when describing counseling a client and client family member: \u003cem\u003e\u0026ldquo;So just really helping them identify when something truly is a problem versus when it's not. Because even [client partner] kept asking me like, \"Is this normal? Is this normal? Is this normal?\" I said, \"It can be normal. We're going to watch all the other signs to make sure that nothing else is out of the normal range,\" right? So it's a matter of like, \"I'm not going to tell you that this is normal because not everybody has this.\" But the thing that's going to indicate that this meconium is problematic is how is the baby dealing with it, right?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMidwives also recognized the healthy tension between patient safety and patient autonomy, and their efforts to balance their clinical expertise and recommendations with preserving the emotional safety that comes with listening to the needs of clients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMaya (midwife), discussing an outside midwifes\u0026rsquo; case where a client refused hospital transfer: \u003cem\u003e\u0026ldquo;Autonomy is an important piece... but I'm like, \"We are supporting women that birth outside of the hospital. Is that not autonomy? Is that not enough autonomy?\" In my head, I'm like, \"She wants to hold her baby.\" This person wanted to hold their baby. It's not taking away her autonomy. It's giving her an opportunity to hold the child she's carried for nine months.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas further reflected in practices described within the interviews, such as asking for permission before physical exams, individualized assessments for home birth eligibility, and careful postpartum practices like placental examination.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMidwifery as Education, Advocacy, and System Navigation\u003c/h2\u003e \u003cp\u003eParticipants described midwives as not only clinicians but also educators and advocates who prepare clients and families to navigate institutional systems. This included childbirth education, nutrition counseling, strategies for advocating within hospitals, and broader efforts to demystify midwifery through community education. Dietary and nutrition counseling was a prevalent service that participants noted, and a fundamental part of Black midwifery care. For example, midwives discussed their approaches to glucose testing and the risks of gestational diabetes, while also balancing client autonomy and intuition:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMaya (midwife): \u003cem\u003e\u0026ldquo;If a mom is going to tell me, \"Hey, I feel this.\" I'm not going to take that for granted because women are so intuitive during their pregnancy... Maybe we can explore it a little bit more. Maybe she may not want a certain thing in her pregnancy...I'm okay with that...because some people do not want to do that glucose test. And I'm okay with that. But I also want you to recognize what are the issues with gestational diabetes. Do you really trust that your diet of what you're eating is low sugar and high protein, healthy fats, and things like that, fruits and vegetables?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAdvocacy was both interpersonal and structural. In some cases, midwives directly communicated with healthcare providers to ensure clients had access to lab work, information, and resources. Some midwives even offered clients specific language and strategies to use in clinical encounters, supporting client advocacy in diverse settings.\u003c/p\u003e\u003cp\u003eDeborah (client), describing counseling from a midwife about how her interactions with conventional medical establishment?: \u0026ldquo;\u003cem\u003eOne thing that she particularly enforced is that if you don't fully understand something, you need to request a copy of the visit notes or the visit summary and you need to ask for a detailed explanation. You are due a detailed explanation. So you either get a follow-up consultation to discuss your additional questions, or you go over your summary and you decide what it is that you don't understand, and you revisit those topics, but you don't just let them go because that's where fear harbors is in the things that you don't understand.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe holistic approach of midwives was exemplified in their dietary, physical activity, and hydration counseling. The effectiveness of the delivery of physical activity messages was notably in the context of societal challenges pregnant clients face in implementing them, including cultural expectations and body image issues.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMia (collaborating provider), about a midwife\u0026rsquo;s care: \u003cem\u003e\u0026ldquo;And it was a little hard because the mama had food aversions and wasn't really nourishing herself enough. But [midwife] convinced her to really commit to herself more, even when this mama didn't want to. This mama had so much fatigue. She was so sweet, but she just didn't want to get off the couch. She wasn't taking her vitamins that much. And [Midwife] lovingly - maybe it was a black woman to black woman thing - got her to do it. She got her to walk. She got her to take all of her vitamins, start drinking smoothies, just took better care of herself.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMidwifery as Cultural and Family Integration Practice\u003c/h2\u003e \u003cp\u003eParticipant interviews identified the importance of culturally grounded midwifery that integrates family and community. Midwives were seen as bridges between clinical care and familial dynamics, helping to facilitate inclusive birthing environments while maintaining client comfort and emotional safety. Midwives were persistently cited by clients, client families, and collaborating providers as important bridges for fathers, and extending education, participation, and emotional safety to them as well.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSamantha (client), about midwifery care she and her family received: \u0026ldquo;\u003cem\u003e[Midwife] made him feel empowered as a Black father by involving him in our visits, by allowing him to participate and be acknowledged and just overall a part of what was going on. He was a vital piece in all of that. She didn't just address me in my care and what I needed to do and exclude my spouse; she included him 100%. She told him ways that he could affirm me every day, ways that he could make sure I was following my diet [laughter]. Just giving us helpful advice on workouts and ways that I can involve my daughter, who was seven at the time. And it was just priceless because we had never experienced that before. With our first daughter, there were rare moments where he was even acknowledged, and he would be with me everywhere we went.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother theme is the strength and tension of family involvement. For example, several participants described the challenges in family integration. One midwife described a case in which a mother's presence at a home birth created emotional distress for the birthing person, prompting a hospital transfer. Often, midwives were recognized by clients for their ability to create respectful spaces where family participation is encouraged without compromising client comfort and safety. These dynamics reflect the importance of intentional and inclusive planning and perhaps more importantly, emotional safety.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNathan (midwife\u0026rsquo;s husband), about the care she provides: \u003cem\u003e\u0026ldquo;And so if there's issues between family members or siblings or children or spouses or whatever and that shit isn't handled, then that will cause issues at the home birth. And it can cause issues at the hospital birth too. But the hospital birth is designed for them to not really be communicating with each other anyways. You go stand over there or go in the other room, so it alleviates it in different ways. But [Midwife] approaches her care from a spiritual communal understanding of birth. This is a family experience. This is not an individual experience. It takes more than one person to create this life. It will take more than one person to raise and foster this life. You are all in this together. Everybody has different roles. And so one of her roles as a provider of midwifery care is just that, to make sure y'all are in this together.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMidwifery as a Spiritual, Ancestral and Emotional Practice\u003c/h2\u003e \u003cp\u003eParticipants expressed that midwifery care is deeply spiritual and emotionally attuned. Social and emotional support was both a prevalent and persistent code within interviews. Spirituality was mainly mentioned by the midwives as a foundational pillar of why and how they do their work. Practices such as building birth altars, using herbs, and creating rituals were described alongside grief support after loss, affirming the midwives\u0026rsquo; role in holding sacred space. Clients who had also experienced hospital care noted that this was unique about Black midwifery\u0026ndash;that there was priority and attention given to the spiritual needs of birthing parents and families.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSamantha (client): \u003cem\u003eBut the fact that [Midwife] came and was just like, \"Is there any part of the birth where it's\u0026ndash;\" we may have a religious or a cultural ritual that we want to do when babies are born in our family that they need to be aware of. Is there anything we want to do with the placenta? Just being asked those questions before experiencing it meant a lot because I was like, \"Wow. Actually, I didn't fully think about it, but now that you asked me, let me make sure. Is there something that I want to make sure I do to honor our family or our beliefs or anything like that?\" And just the fact that she asked, that meant a lot to me.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClients noted this type of care in the context of pregnancy loss as well, from miscarriage to previous choices to have an abortion. One client describes her midwife\u0026rsquo;s integration of spirituality to honor life and grief while having a home delivery of a stillborn.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTania (client): \u003cem\u003e\u0026ldquo;Before [Midwife] left, she gave me this little satchel, and the satchel had flowers and herbs and everything. And she said, \"When you have your baby, you can bury your baby with this.\" She gave me the idea of having a ceremony for my baby. So nobody had ever told us anything like that before. Nobody even gave it that type of sacredness. So I was careful to make sure that I captured it. I captured it. I wrote a letter to the baby. My husband got a chance to write a letter to the baby. We did our ceremony. We had the herbs and everything, and we buried our baby. So that was beautiful. Even though that ended in loss, it was so empowering to me because first of all, I did it by myself.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMidwives themselves called on deep wells of ancestral knowledge, intuition, and non-Western frameworks to provide care that bridges the spiritual and the clinical. In the excerpts, interviewees reflected on midwifery as an ancestral calling, with birth viewed as a sacred and divinely guided experience.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMaya (midwife), describing the spirituality in her care: \u003cem\u003e\u0026ldquo;So you might smell something and say, \"Something smells like it's not right,\" right? And you're using these skills...to identify that there may be a problem that's coming up. Or you might feel something in a certain part of your body, and you're tuning into the things, and you're helping that mother tune into those things...What do you feel? What do you smell?...And then on top of that...it's how is this person connecting in a spiritual way. And it can be anything. It could be your God...it could be your ancestors. How is that individual connecting to their spiritual side? Because we're deeper beings. I mean, there's so much that makes us who we are. I think that's what I would say about traditional midwifery.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSierra (midwife), describing being called to midwifery: \u003cem\u003e\u0026ldquo;...Those of us that are called to do this work as midwives in a community-based setting, really, I feel like have been divinely appointed, right? Because it's almost like we're fighting for human rights to some degree\u0026hellip;As I was ending the last part of my clinical training, and I was like, \"Oh, my God. I don't think I can make it. This is too much. It's too hard.\" And then my grandmother called me one day out of the blue and was like, \"[Midwife...] Did you know your great-great-grandmother was a grand midwife who practiced in the South?\"...I knew immediately that was a sign from God telling me that I was doing exactly what I was supposed to do in this time in history right now. And that was just the field that I needed to get over the line, to complete it, to finish it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite a growing body of literature on the history and resurgence of Black midwifery, there remains limited empirical research on its day-to-day practices. This study addresses that gap through a large-scale qualitative analysis of the services and values that define Black community midwifery in practice. We identified eleven services that Black community midwives provide and four primary values that guide their services. Additionally, educating and integrating the family unit, social emotional support/counseling, and dietary and nutrition counseling were the most reported services provided by midwives. Our study highlights Black community midwifery as a holistic, culturally grounded, and spiritually infused model of care. Across interviews, deep care emerged as a defining value, with clients describing familial, affirming, and attentive support that reflects a moral, emotional, and political commitment to sustaining life in the face of systemic harm.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e These experiences align with literature showing greater perceived self-efficacy, autonomy, and respect in community birth settings compared to physician-led hospital births.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Midwives skillfully balanced patient autonomy and patient safety, emphasizing informed consent as an ongoing dialogue. They honored clients' bodily knowledge while maintaining clinical oversight, reflecting an ethical and clinically sound model of care.\u003c/p\u003e \u003cp\u003eIn the context of Black midwifery and otherwise, deep care is a politically rooted form of healing grounded in Black feminist thought.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Furthermore, it represents an extension of longstanding theories of care as both relational and political practice.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This reframes care as a radical act of survival and communal resistance, rather than passive support. It becomes \u0026ldquo;a philosophy of survival in the face of literal and psychic death,\u0026rdquo; disrupting negative outcomes by centering collective well-being, spiritual connection, and ontological resistance to state-sanctioned neglect and violence.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Black midwives embody this through ancestral knowledge and attention to bodily, emotional, and spiritual wellness\u0026mdash;echoing practices like storytelling, spiritual herbalism, and community ritual highlighted in Black feminist healing modalities.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e In this sense, deep care reflects what has been described as \u0026ldquo;freedom work\u0026rdquo;\u0026mdash;a practice that transforms care labor into a collective project of survival and liberation.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e These acts of care reflect both clinical attentiveness and a sustained ethical stance, i.e., a refusal of disposability and an insistence on relational repair as central to health.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis form of care resists commodified, institutionalized models of wellness by reclaiming caregiving as sacred and culturally rooted, which is especially critical in a healthcare system that has violated and marginalized Black birthing people. Notably, the Black midwives interviewed in this study practiced a form of deep care that both includes and transcends clinical support and is shaped by Black feminist epistemologies that prioritize dignity, healing, and joy amid structural harm. This aligns with evidence that Black birthing people associate safety and well-being not only with clinical competence but with being cared for \u0026ldquo;from a place of love,\u0026rdquo; in spaces that affirm shared identity and trust.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Importantly, Black midwifery prioritizes love as a tool for promoting and protecting health and wellbeing. This love ethic, grounded in care, respect, and responsibility, reframes healing as a collectivist, justice-led act.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Through this, Black midwifery centers generative relationships that restore dignity, connection, and collective safety.\u003c/p\u003e \u003cp\u003eMidwives were also described as educators and system navigators, preparing clients to advocate for themselves in institutional spaces and supporting holistic health through dietary and physical activity counseling. They communicated this information sensitively and with the client\u0026rsquo;s individual needs, resources, and emotional well-being in mind. This dimension of care further reflects midwives\u0026rsquo; dual role as clinicians and community educators, translating love and responsibility into actionable guidance and advocacy. This is crucial, particularly given that pregnant individuals who experience body dysmorphia or negative body image are at risk of experiencing lower quality of life and worse pregnancy outcomes.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Midwives' ability to center relationships and tailor interventions was key to supporting behavior change in these contexts. The findings further underscore the cultural and family-centered nature of Black midwifery care. Midwives intentionally integrated fathers, children, and extended family into birthing processes while prioritizing emotional safety. Spiritual care was another cornerstone, with midwives drawing from ancestral practices to create sacred spaces around birth and loss. This is particularly notable given the historical marginalization of Black midwifery, which traces its roots to West African traditions disrupted by the rise of white midwifery and obstetrics.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Rituals around birth and loss, attention to spiritual connection, and references to ancestral calling situate Black community midwifery within broader traditions of sacred care work. This framing challenges dominant biomedical paradigms that often divorce birth from emotional, spiritual, and cultural contexts, reinforcing Black midwifery\u0026rsquo;s critical role in offering care that addresses the full humanity of Black birthing people.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eCurrent approaches to the Black maternal health crisis often center hospital-based interventions. Our findings demonstrate that Black midwives play a critical role in improving outcomes through community-rooted, culturally grounded care. Models such as Beloved Birth Black Centering show that when care is co-designed with Black midwives, doulas, and families, it fosters trust, safety, and systemic accountability.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Policy efforts should expand Medicaid reimbursement for community midwifery and doula care, invest in Black-led birth centers, and support groups and wraparound care models. These strategies shift maternal health policy from reactive measures to structural repair, advancing a system where safety and justice are inseparable. Such investments align with current federal and state priorities under the Title V Maternal and Child Health Program and the Black Maternal Health Momnibus Act, which emphasize culturally congruent care, diversification of the perinatal workforce, and sustained funding for community-based maternal health organizations.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study is rooted in the personal narratives of Black community midwives and those most directly impacted by their care. Inherently, this is a strength as it offers nuanced and community-led insight\u0026mdash;one that might be difficult to access from an institution-led lens. Additionally, this study surveyed and interviewed clients from several regions of the United States\u0026mdash;all with different practice regulations. Interviewees were diverse, and this allows for a more inclusive picture of Black community midwifery. Finally, including key informants like collaborating providers, community stakeholders, and family members allows for a wrap-around view of midwifery care\u0026mdash;and its ripple effects on family, community, and institutional structures.\u003c/p\u003e \u003cp\u003eThis study is somewhat limited by a lack of socioeconomic diversity\u0026mdash;which is representative of a larger barrier to care. Typically, clients seeking community midwives or home birth must pay out of pocket, even if they are insured. The cost of a homebirth can be anywhere from 5500\u0026ndash;8000\u003cspan\u003e$\u003c/span\u003e, limiting access to those who can afford it.\u003csup\u003e24\u003c/sup\u003e Many of the clients in this study paid out of pocket, which potentially limits the generalizability of these results to low-income birthing people. Additionally, this study utilized purposeful and snowball sampling. To participate in the study, clients had to be referred by the midwife. This might limit the study to clients who had positive relations with the midwife and potentially impacts the transferability of this study to larger populations. Of note, we interviewed a client who terminated her relationship with the midwife around labor. In that interview, the same values emerged.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFuture Directions\u003c/h2\u003e \u003cp\u003eBlack community midwifery is a powerful avenue for addressing disparities in maternal health and could be critical to improving outcomes around physical and emotional safety for Black birthing people. Future studies should look towards the barriers that midwives face, as well as the resources they need to ensure this case is accessible for clients and sustainable for birth workers. Future research should also investigate the demand or preference for care attributes of the Black community midwifery in the general Black birthing population. Importantly, increasing the number of Black midwives through targeted recruitment and financial support in educational programs will be crucial. Additionally, investing in community-based birthing centers and expanding Medicaid coverage to include midwifery services are also vital steps toward creating a more inclusive and effective maternal healthcare system. Importantly, this study highlights the need for a care paradigm that supports Black birthing people, communities, and midwives\u0026mdash;rather than one that lionizes them or overemphasizes their resilience in the face of structural oppression.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study illuminates the vital role Black community midwifery plays in addressing the multifaceted crisis of Black maternal health. By centering \"deep care\"\u0026mdash;a culturally grounded, emotionally attuned, and spiritually connected model of care\u0026mdash;Black midwives provide affirmative support that goes far beyond clinical procedures. Their approach prioritizes education, autonomy, safety, advocacy, and family integration, all while drawing from ancestral knowledge and community wisdom. These values resonate deeply with Black birthing people seeking affirming, respectful, and holistic alternatives to institutionalized maternity care. The findings of this study affirm what generations have long known: Black midwifery is not only a practice of catching babies but one of catching families, communities, and histories. As the U.S. grapples with comparative poor over maternal health and serious disparities in maternal experience and outcomes, investing in Black midwifery is imperative. Sustained support for education, policy reform, Medicaid expansion, and culturally rooted birthing infrastructure can ensure that the future of maternal health is not only safer, but more just.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCNM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCertified nurse-midwife\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCertified professional midwife\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCertified midwife\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMothers on Respect index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMADM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMothers Autonomy in Decision Making scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics Approval and Consent to Participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health (IRB #25161). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants were informed about the purpose of the study, assured of confidentiality, and provided written and verbal consent prior to participation. Participation was voluntary, and respondents could withdraw at any time without consequence.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for Publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants provided informed consent for the publication of de-identified interview excerpts and qualitative data. No identifying information is included in this manuscript, pseudonyms are used in lieu of names.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of Data and Materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Robert Wood Johnson Foundation (RWJF Grant #142141, Award ID# 80002). The funder had no role in the study design, data collection, analysis, interpretation, or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor\u0026rsquo;s Contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCB led the drafting of the manuscript and contributed substantially to data analysis, interpretation, and critical revisions. AM, JM, KPP, DAD, and KF contributed to study conception and design, methodology, data collection, analysis, and manuscript revisions. DAD and KF provided project supervision. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend deep gratitude to the Black midwives, clients, families, collaborating providers, and community stakeholders who generously shared their experiences and expertise. We thank Marjorie Paloma, Program Officer at the Robert Wood Johnson Foundation, for her support, and Ebonie Megibow for her contributions to codebook development. This work would not have been possible without the wisdom and leadership of Black midwives and the communities they serve.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRobinson SA. A historical development of midwifery in the black community: 1600\u0026ndash;1940. \u003cem\u003eJ Nurse Midwifery\u003c/em\u003e. 1984;29(4):247-250. doi:10.1016/0091-2182(84)90128-9\u003c/li\u003e\n \u003cli\u003eTunc TE. The Mistress, the Midwife, and the Medical Doctor: pregnancy and childbirth on the plantations of the antebellum American South, 1800\u0026ndash;1860. \u003cem\u003eWomens Hist Rev\u003c/em\u003e. 2010;19(3):395-419. doi:10.1080/09612025.2010.489348\u003c/li\u003e\n \u003cli\u003eGoode K, Katz Rothman B. African-American Midwifery, a History and a Lament. \u003cem\u003eAm J Econ Sociol\u003c/em\u003e. 2017;76(1):65-94. doi:10.1111/ajes.12173\u003c/li\u003e\n \u003cli\u003eMcCoy L. Black Midwifery in the US. Western Center on Law \u0026amp; Poverty. February 27, 2024. Accessed February 28, 2025. https://wclp.org/black-midwifery-in-the-us/\u003c/li\u003e\n \u003cli\u003eThomasson MA, Treber J. From home to hospital: The evolution of childbirth in the United States, 1928\u0026ndash;1940. \u003cem\u003eExplor Econ Hist\u003c/em\u003e. 2008;45(1):76-99. doi:10.1016/j.eeh.2007.07.001\u003c/li\u003e\n \u003cli\u003eMehra R, Alspaugh A, Joseph J, et al. Racism is a motivator and a barrier for people of color aspiring to become midwives in the United States. \u003cem\u003eHealth Serv Res\u003c/em\u003e. 2023;58(1):40-50. doi:10.1111/1475-6773.14037\u003c/li\u003e\n \u003cli\u003eBackes EP, National Academies of Sciences E, Division H and M, et al. Maternal and Newborn Care in the United States. In: \u003cem\u003eBirth Settings in America: Outcomes, Quality, Access, and Choice\u003c/em\u003e. National Academies Press (US); 2020. Accessed February 28, 2025. https://www.ncbi.nlm.nih.gov/books/NBK555484/\u003c/li\u003e\n \u003cli\u003eHoyert DL, Mini\u0026ntilde;o, Arialdi M. National Vital Statistics Reports Volume 69, Number 2 January, 2020. Published online January 30, 2020.\u003c/li\u003e\n \u003cli\u003eKarbeah J, Hardeman R, Katz N, Orionzi D, Kozhimannil KB. From a Place of Love: The Experiences of Birthing in a Black-Owned Culturally-Centered Community Birth Center. \u003cem\u003eJ Health Disparities Res Pract\u003c/em\u003e. 2022;15(2):47-60.\u003c/li\u003e\n \u003cli\u003eDe Ornelas M, Harley KG, Davis D, et al. A Community‐Centered and Antiracist Model of Whole‐Person Perinatal Care: Beloved Birth Black Centering. \u003cem\u003eJ Midwifery Womens Health\u003c/em\u003e. 2025;70(3):468-475. doi:10.1111/jmwh.13761\u003c/li\u003e\n \u003cli\u003eWelch L, Branch Canady R, Harmell C, White N, Snow C, Kane Low L. We Are Not Asking Permission to Save Our Own Lives: Black-Led Birth Centers to Address Health Inequities. \u003cem\u003eJ Perinat Neonatal Nurs\u003c/em\u003e. 2022;36(2):138-149. doi:10.1097/JPN.0000000000000649\u003c/li\u003e\n \u003cli\u003eHobart HJK, Kneese T. Radical Care: Survival Strategies for Uncertain Times. \u003cem\u003eSoc Text\u003c/em\u003e. 2020;38(1 (142)):1-16. doi:10.1215/01642472-7971067\u003c/li\u003e\n \u003cli\u003eFinch AK. Introduction: Black Feminism and the Practice of Care. \u003cem\u003ePalimpsest\u003c/em\u003e. 2022;11(1):1-41.\u003c/li\u003e\n \u003cli\u003ehooks bell 1952-2021. \u003cem\u003eAll about Love : New Visions\u003c/em\u003e. First edition. New York : William Morrow, [2000] \u0026copy;2000; 2000. https://search.library.wisc.edu/catalog/999884519302121\u003c/li\u003e\n \u003cli\u003eDavis DA, Craven C. \u003cem\u003eFeminist Ethnography: Thinking through Methodologies, Challenges, and Possibilities\u003c/em\u003e. Rowman \u0026amp; Littlefield; 2022. Accessed October 21, 2025. https://books.google.com/books?hl=en\u0026amp;lr=\u0026amp;id=3SlgEAAAQBAJ\u0026amp;oi=fnd\u0026amp;pg=PP1\u0026amp;dq=info:7b9aiT9Ox8QJ:scholar.google.com\u0026amp;ots=zDuhokCYLR\u0026amp;sig=d6wAoD6WtfRUwRYgSd3TyMm0wuA\u003c/li\u003e\n \u003cli\u003eVedam, Saraswati. The Mother\u0026rsquo;s Autonomy in Decision Making (MADM) scale: Patient-led development and psychometric testing of a new instrument to evaluate experience of maternity care | PLOS One. 2017. Accessed April 22, 2025. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0171804\u003c/li\u003e\n \u003cli\u003eKittay EF. The Ethics of Care, Dependence, and Disability*. \u003cem\u003eRatio Juris\u003c/em\u003e. 2011;24(1):49-58. doi:10.1111/j.1467-9337.2010.00473.x\u003c/li\u003e\n \u003cli\u003eSu\u0026aacute;rez-Baquero DFM, Joseph J, McLemore MR. Traditional Black Midwifery to Enhance Birth Justice. \u003cem\u003eJ Obstet Gynecol Neonatal Nurs\u003c/em\u003e. 2024;0(0). doi:10.1016/j.jogn.2024.07.003\u003c/li\u003e\n \u003cli\u003eNiles PM, Baumont M, Malhotra N, et al. Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter? \u003cem\u003eReprod Health\u003c/em\u003e. 2023;20(1):67. doi:10.1186/s12978-023-01584-1\u003c/li\u003e\n \u003cli\u003eBogan EV, Harr ED. Health Equity Through Black Feminist Healing: A Narrative Review on the Contributions of Black Womxn to Integrative Medicine. \u003cem\u003eGlob Adv Integr Med Health\u003c/em\u003e. 2025;14:27536130251332568. doi:10.1177/27536130251332568\u003c/li\u003e\n \u003cli\u003eNadasen P. \u003cem\u003eCare: The Highest Stage of Capitalism\u003c/em\u003e. Haymarket Books; 2023.\u003c/li\u003e\n \u003cli\u003eGibson AH, Zaikman Y, Rodriguez R, Bennett B. The effects of body dysmorphic disorder on women\u0026rsquo;s quality of life and body image at difference stages of pregnancy. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2024;24(1):653. doi:10.1186/s12884-024-06857-6\u003c/li\u003e\n \u003cli\u003eThe Momnibus Act | Black Maternal Health Caucus. March 7, 2020. Accessed October 21, 2025. http://blackmaternalhealthcaucus-underwood.house.gov/Momnibus\u003c/li\u003e\n \u003cli\u003eAnderson DA, Gilkison GM. The Cost of Home Birth in the United States. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2021;18(19):10361. doi:10.3390/ijerph181910361\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aoph","sideBox":"Learn more about [Archives of Public Health](http://archpublichealth.biomedcentral.com/)","snPcode":"13690","submissionUrl":"https://submission.nature.com/new-submission/13690/3","title":"Archives of Public Health","twitterHandle":"@Archpubhealth","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Black community midwifery, maternal health equity, deep care, Black maternal health, qualitative research, birth justice","lastPublishedDoi":"10.21203/rs.3.rs-8348707/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8348707/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eBlack community midwifery has historically offered holistic, culturally grounded care for Black birthing people, yet remains marginalized within modern maternity systems. As disparities in Black maternal health outcomes persist, this qualitative study explored the values, services, and impacts of Black community midwifery across multiple U.S. regions.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eUsing in-depth interviews, observations, and surveys with five midwives and 53 clients, family members, providers, and community stakeholders, we conducted inductive and deductive coding to identify core themes.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eAnalysis revealed 11 primary midwifery services\u0026mdash;including family integration, social-emotional support, and dietary counseling\u0026mdash;and five guiding values: deep care, patient autonomy, patient safety, lived experience, and spirituality. Deep care, a model that integrates clinical, emotional, cultural, and spiritual dimensions, emerged as the most persistent and defining value across participant narratives. Midwives were described as educators, advocates, and system navigators who fostered client autonomy while balancing clinical safety. Family and spiritual integration were critical components of care, particularly during birth and pregnancy loss. Clients reported greater self-efficacy, trust, and emotional wellbeing compared to conventional healthcare settings.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eFindings underscore Black community midwifery as a vital strategy for advancing maternal health equity. We recommend expanded investment in midwifery education, community-based birth infrastructure, and supportive policy reforms.\u003c/p\u003e","manuscriptTitle":"Deep Care: A Qualitative Analysis of Black Community Midwifery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 15:57:42","doi":"10.21203/rs.3.rs-8348707/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-18T16:43:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T15:01:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T08:45:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"207663438739625484667428101689612863888","date":"2026-01-29T16:01:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T00:41:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224643966027184628690747563838012744852","date":"2026-01-28T06:10:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44312157791993081628589950101351463623","date":"2026-01-27T22:24:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T03:56:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-30T11:49:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-29T14:15:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Public Health","date":"2025-12-26T20:40:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aoph","sideBox":"Learn more about [Archives of Public Health](http://archpublichealth.biomedcentral.com/)","snPcode":"13690","submissionUrl":"https://submission.nature.com/new-submission/13690/3","title":"Archives of Public Health","twitterHandle":"@Archpubhealth","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa9583a0-6823-46ca-a099-bd7aceef68b8","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T12:43:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-08 15:57:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8348707","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8348707","identity":"rs-8348707","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}