COVID-19 & Birth Equity

Jul 31, 2020


Raise Colorado’s Infant and Maternal Mortality Prevention Workgroup and partners submitted this letter to the Office of Health Equity of the Colorado Department of Public Health and Environment (CDPHE) to help inform the state’s response to birth equity during the COVID-19 public health crisis. We encourage advocates to share the letter with their networks to bring attention to needed actions to remove barriers that perpetuate racial disparities and improving infant and maternal health in Colorado. A printable version of the letter is available in our GoogleDrive folders.

Jul. 30, 2020

To: Office of Health Equity (

From: Infant and Maternal Mortality Policy Workgroup of Raise Colorado; A Mother’s Choice Midwifery; Colorado Children’s Campaign; Elephant Circle

Subj: COVID-19 and Birth Equity

Dear Office of Health Equity:

Thank you in advance for the opportunity to inform the state’s equitable response to the COVID-19 pandemic. We know these are trying times and we appreciate all the time and energy the state has dedicated to mitigating impacts of the public health crisis.

The Infant and Maternal Mortality Prevention Workgroup (IMMP) is a Raise Coloradoi sub-group made up of birth experts, infant and maternal health advocates and community leaders. We are committed to removing barriers that perpetuate racial disparities and improving infant and maternal health in Colorado. We’ve included brief summaries of co-author organizations and experts we reference throughout this letter.

In April, after Elephant Circleii and Colorado Organization for Latina Opportunity and Reproductive Rightsiii (COLOR) co-authored a letter to the Governor highlighting birth equity during the pandemic, IMMP and the Colorado Children’s Campaigniv partnered with the Colorado Department of Public Health and Environment (CDPHE) to virtually convene birth experts across the state. We hosted three meetings in which we spoke with hospital providers and administrators, community birth professionals, community and health advocates, and rural providers to hear their most urgent needs, concerns for their birthing community during the pandemic, especially as it relates to racial disparities and the exacerbation there of, and potential state-level solutions.

Using the stakeholder feedback we heard in April and May, we are writing to help inform the state’s response to birth equity during COVID-19 public health crisis. The letter is organized by first stating a request, followed by the concerns we’ve heard, described as our rationale for the request. It is important to note that although many of these concerns and requests came up in our recent conversations around COVID-19, they are not new. Conversations around birth equity and integration of care to better include community providers and culturally relevant care have been underway for years and are just made more critical by our current public health crises, which has and will continue to exacerbate disparities if the state doesn’t take thoughtful action.

Request: Update the language describing racial inequities on the Covid-19 Equity Response Team’s website to center the work in historical, systemic and institutional racism as the root causes of racial disparities. For Example:

      • Instead of “…During this pandemic, we are likely to see the loss of life from racial disparities, and action must be taken.” Say, “During this pandemic, we are likely to see the loss of life from the compounded experience of systematic, institutional and individualized racism imposed on communities of color”.

Rationale: It’s important to describe racial disparities as a symptom of racism and white supremacy. This ensures the community that the state and Health Equity Response Team is genuinely committed to equity. As noted in CDPHE’s statement on structural inequity, policies, institutions and organizations throughout our nation’s history have created systems in which the resources needed to be healthy and opportunities for health are not equitably distributed. These inequities have a greater influence on health outcomes than either individual choices or the provision of health care. Currently, the language used to describe racial disparities on the Response Team’s website fails to highlight white supremacy culture, as well as historical, institutional, or systemic racism, as the root causes of current-day disparities that are being exacerbated by the pandemic. A point that national birth advocacy groups recently reinforced, racism, not race, is the risk factor responsible for disparate health outcomes.

Request: Ask the Governor to issue an executive order that:

      • explicitly defines community birth workers, such as certified professional midwives, doulas (regardless of practice setting), community lactation consultants, and nurse midwives working at free-standing birth centers, as essential healthcare providers;
      • requires local health departments to reserve a sufficient amount of their personal protective equipment (PPE), for community birth workers. The PPE set aside should include masks, shields, gloves and cleaning supplies; and
      • amends the Statewide COVID-19 Testing Strategy so that community birth professionals, as described above, are explicitly considered a tier one priority for COVID-19 testing.

Rationale: There has been a surge in demand for PPE since the first case of COVID-19 presented in early March and community birth workers have experienced barriers that prevented them from accessing their share of state PPE resources. During our conversations in April and May, most of the community birth workers in attendance said they were denied access to PPE at their local health departments. After hearing this concern, hospital providers were asked if they were experiencing the same problem, to which most responded that they were not.

State guidance clearly indicates that community-based providers are essential and should have access to PPE through their local public health departments (public health orders 20-24, 20-23, 20-22, community testing site guidelines, and COVID-19 resources for health care providers), however, as indicated above, most, if not all, of the community and out of hospital providers we spoke to were denied PPE and are relying on private donations and grants or their own means to acquire protective gear. And, although we know that CDPHE staff elevated this issue within the department and outreached local health departments, we fear that in the event of another abrupt surge, without community-provider-specific guidance and explicit protocol, community-based providers will again be sidelined. An Executive Order would provide community birth workers with easy-to-point-to guidance that they could share with their local health departments when seeking PPE supplies.

Request: Encourage the Governor to issue a statement on birth equity that:

      • acknowledges the importance of community-birth professionals and their essential role to ensure safe and equitable care across the state;
      • highlights the lack of integration of community birth into the state’s healthcare system and calls on birthing stakeholders to work together over the summer and in future years to develop policy solutions that would create a better integrated maternal health care system in Colorado;
      • recommends that local and state COVID-19 relief funds are distributed equitably so communities facing the most barriers are prioritized so that hospitals and providers located in high-need areas or providing care to underserved populations including uninsured, rural populations, people with low income, Medicaid enrollees, and communities of color are prioritized; and

      • calls on all birth settings to examine their policies and practices to ensure they are delivering equitable care. The statement could point to CDPHE’s COVID-19 Labor and Delivery and Breastfeeding Guidance which emphasizes the importance of shared decision making and when to consider allowing additional support in the birthing room and additional resources listed below.

      • Birth Place Lab’sv Best Practice Guidelines: Transfer from Planned Home Birth to Hospital offers guidance for responsible patient transfer between community birth and hospital birth which will improve the integration of midwifery in Colorado – an important element of access to equitable birth options and care.
      • National Academy of Science, Engineering and Medicine’svi (NASEM) Feb. 2020 report Assessing Health Outcomes by Birth Settings, which provides guidance on how to improve care in all birth settings and better integrate community and hospital birth. For example, “hospitals can ensure that pregnant people receive respectful, appropriate, timely, and responsive care by providing nonsurgical maternity care services if requested, such as vaginal birth after a prior cesarean birth. Hospitals can also consider developing midwifery-led units for low-risk births and enabling greater collaboration between midwives, doctors, and nurses.”
      • Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. This study, co-authored by international leaders in reproductive health and birth equity and community stakeholders with lived experiencevii highlights the experience of birthing people across the United States. The report is disaggregated by race, birth setting and type of provider and experience is examined through autonomy, respect and trust.
      • National Partnership for Women and Families’viii issue brief, Maternity Care in the United States illuminates the systemic shortcomings of health care system in the U.S. and outlines implications for policy and cultural change.

Rationale: Collaborative care throughout the antepartum, intrapartum, and postpartum periods is crucial to safety in all birth settings. However, because Colorado hasn’t properly integrated community care into the state’s overall healthcare structure, community-birth providers and community-birth patients face more barriers to delivering and receiving safe quality care. We’ve heard that the pandemic is exacerbating these barriers and jeopardizing care. For example, we heard that community midwives across the state have had trouble finding an obstetrician who would accept a patient transfer from them. One community midwife shared with us that, on more than one occasion and at various times during their patients’ pregnancy, both clinical and hospital obstetricians were unwilling to accept a direct transfer of care of patients who presented with serious conditions requiring a higher level of care. In fact, some of these providers discussed that a patient in the third trimester could simply walk into the emergency department when in labor to give birth, which is patently inadequate prenatal care. Colorado must do better, now and in the future to integrate community birth into the state’s health care structure, a request that community-birth providers have advocated for, for decades.

Request: Support CDPHE in identifying and sharing COVID-19 and pregnancy related information –in multiple language –community facing organizations and hospital providers.

Rationale: Although CDPHE has developed and translated many Covid-19 and birth specific resources, we’ve heard that this public health information is not reaching the community as well as it could be, especially for families who speak English as a second language. CDPHE has effectively outreached to local health departments and community health centers, but we believe that the state departments (CDPHE, HCPF & CDHS) could outreach collaboratively to better reach community-facing organizations to share priority information in several languages. Priority information should include what it means to be tested for COVID-19 and how care or birth experiences might be affected by evolving state and hospital guidelines.

Many of the resources already exist or are being created as we speak, but need to be distributed more broadly. For example, The COVID-19 Colorado website is available in six different languages, including a pregnancy and breast-feeding specific page. Local organizations have also provided useful information the Team could share, such as Elephant Circle & COLOR’s bilingual hotline for pregnant people, that could be included resource outreach.

Request: Recognize the expertise of the groups who initiated these conversations, Elephant Circle and COLOR, and begin to build professional working relationships.

Rationale: Local organizations with expertise in maternal biology, birth equity, reproductive justice, and much more, led by or representing people of color such as COLOR, A Mother’s Choice Midwiferyix, Elephant Circle and many, many others have been advocating for equity-based policy changes for decades. Unfortunately, much of their advocacy has either fallen on deaf ears or is credited to their white partners. Despite our best intentions, these actions perpetuate white supremacy and inequality. In order to do our best work, we must make amends to those we’ve harmed.

On March 13, Elephant Circle and COLOR co-wrote a letter to the Governor. They highlighted birth equity concerns as they’ve tracked them in Colorado and made plain policy related requests to mitigate exacerbated racial birth inequities due to the pandemic. The letter sparked interest among several groups and stakeholders, however, the work that followed, including the decisions around birth-related pandemic polices, failed to include the expertise outlined in that letter. Collectively, the people who contributed to the birth equity letter have spent more than 50 years working in community birth in Colorado. And yet, their voices were disenfranchised from the conversation, almost immediately. Building relationships with and trusting the expertise of the community and community-focused organizations is critical achieving our goal of ensuring Colorado policy benefits everyone.

Elephant Circle, COLOR, and A Mother’s Choice Midwifery collaborated with the Children’s Campaign, CDPHE and the Infant and Maternal Mortality Policy Workgroup throughout our conversation regarding birth equity and in developing this letter. Their content expertise was the main source of our recommendations and without their participation, this letter may not have come to fruition or it would have seriously lacked meaningful request. Thank you again for your time and we look forward to following up with you all as we are happy to assist in any way viably possible.


The Infant and Maternal Mortality Prevention Workgroup of Raise Colorado

A Mother’s Choice Midwifery

Colorado Children’s Campaign

Elephant Circle


i. Raise Colorado is a coalition of organizations, parents, advocates, businesses, service providers and government representatives that support the growth of Colorado’s youngest children and their families through public awareness, policy development and advocacy efforts.

ii. Elephant Circle is a local birth justice organization made up of experts in the health, legal and biological systems related to the perinatal period, who provide a wide array of services at the micro, mezzo and macro level.

iii. Colorado Organization for Latina Opportunity and Reproductive Rights is a reproductive justice organization that works to address the disparate impacts that systemic barriers create for individuals due to their economic situation, faith, race, gender, age, immigration status, physical abilities, sexual orientation, or gender identity.

iv. The Colorado Children’s Campaign is a non-profit, non-partisan research and advocacy organization that believes in every chance for every child.

v. The Birth Place Lab is a multidisciplinary research center of The University of British Columbia that centers community-based participatory research and knowledge translation to improve access to high quality maternity health care information across birth settings. The Lab’s guidelines seek to help foster effective collaboration by addressing the various levels of interactions between care providers. This includes discussion, consultation, collaboration, and transfer of care from one provider to another. It makes sense to use their expertise as the foundation of the state’s response as we know transfers between community-based care and hospital-based care are likely to increase during the pandemic response.

vi. The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide expert advice on some of the most pressing challenges facing the nation and world. Their work helps shape sound policies, inform public opinion, and advance the pursuit of science, engineering, and medicine.

vii. The Giving Voice to Mothers Study was co-created with Women from five communities of color, and women who planned to give birth at home or in a birth center and the Birth Place Lab. The women developed a survey with over 200 questions describing their experiences of pregnancy, birth, prenatal and newborn care. Also, they decided what to study, designed the questions, and recruited participants. To ensure rigor and ethical conduct in all aspects of the research, they collaborated with the Birth Place Lab team.

viii. The National Partnership for Women and Families is a non-profit, non-partisan organization that works to works to change policy and culture. They are grounded in the lived experience of women and families.

ix. A Mother’s Choice Midwifery is a home-birth clinic located in Colorado Springs. It is owned and operated by Demetra Seriki, the only black home-birth-midwife in Colorado.