When Upstream Public Health Efforts Fall Short

Over nearly 20 years working in public health I have noticed an increase in individual and organizational commitment to “health equity". But as I explain in this piece “When Upstream Public Health Efforts Fall Short”, in spite of commonly shared definitions references to the social determinants of health, there is not a shared analysis about why inequities exist. And how we define the problem, shapes the meaning we make, the conclusions we draw, and the actions we take. (Spoiler alert: the problem is structural.)


Imagine receiving personalized prenatal care from a highly skilled provider team led by licensed midwives, who share a deep dedication to comprehensive parent-centered care. You will have time in your appointment to build relationships your providers, and receive the kind of care you want and that is best for you and baby.

Imagine building community with other pregnant and parenting families through childbirth education classes, in prenatal yoga, or in group meditation.

Whoever you want to be part of your care and birth experience is welcome at the birth center - your grandfather, your best friend, your Capoeira teacher, and/or your 3 year old. In addition to being by your side, they can also find comfort in the beautiful living room and kitchen while you labor.

Neighborhood Birth Center will engage a community of doulas offering continuous physical, emotional and informational support before, during and after childbirth. Access to healers offering yoga, meditation, reiki, massage, pelvic floor physical therapy, chiropractic, and acupuncture, and mental health practitioners offering psychotherapy, counseling, and support groups. All of these supports as well as lactation & nutrition support, childbirth classes, and new parent groups are important to pregnant people and new parents and should be easily accessible in one place.

When you arrive at the birth center in labor, you will receive the best and safest of care from highly skilled midwives and birth assistants whose training centers on the fact that pregnancy and birth are normal life processes. You will have access to one of the beautifully designed state of the art birthing suites featuring a luxurious and specially-designed tub, and large walk in shower for the comfort warm water provides in labor. You will also have the option of nitrous oxide, or laughing gas, to help manage pain through labor. (Supplies and safety equipment are easily accessible but not overwhelming in the space.) In addition to sitting or leaning on the birth ball or stool for comfort, you can use Swedish bars securely built into the wall or sling anchored to the ceiling to support you in a squat or leg raise to open your pelvis. All of this could help move baby down the birth canal and provide some pain relief. You may choose to wrap yourself in a plush robe and you will have the freedom to move around the space as your body needs.

You can get some fresh air on a small private balcony or just open the doors while you relax in bed. You can customize the space with your own music, or other accessories to make it feel like home.

"The birth center approaches pregnancy and birth as a normal family event until proven otherwise. [And] encourages family involvement and provides a safe environment for families to experience the social, emotional, and spiritual renewal inherent in birthing forth new life while attending to the possibility that a problem may arise that will require medical intervention or care in the acute care setting of the hospital. This is in opposition to the view that pregnancy is an illness and birth a medical/surgical event that needs to be cured." -American Association of Birth Centers

When baby is born, you will have time to relax and bond. The team will provide extensive breastfeeding teaching and help to get you off to a wonderful start. Once you are ready to go home you will have supports in place for you and your baby’s wellness, including a home visit in the first 2-3 days and warm, welcoming office visits at 2weeks and 6 weeks postpartum.

This is possible. This is coming. Allow yourself to imagine.

On Belonging...

It is a radical and necessary act to love ourselves and each other enough to create the changes we need.

Neighborhood Birth Center emerged out of the stories, frustrations, and longings of people and families who are usually not centered in the design of health care spaces: Black, Brown, and Indigenous, youth, immigrant, LGBTQ+, low-income and others. We recognize that in our vision and design of the space we must center the physical, emotional, and spiritual healing and care for people at the margins. We do this with joy, because everyone belongs here.

“Belonging means more than just being seen. Belonging entails having a meaningful voice and the opportunity to participate in the design of social and cultural structures. Belonging means having the right to contribute to, and make demands on, society and political institutions.

Belonging is more than just feeling included. In a legitimate democracy, belonging means that your well-being is considered and your ability to design and give meaning to its structures and institutions is realized.” -john powell

In our commitment to establishing a freestanding birthing center in Boston, we do not subscribe to health equity work that merely “services” communities of color, while staying apolitical, maintaining the status quo, or exacerbating inequity. There are traumatizing patterns of racial inequities in birth outcomes and pregnancy care in the US, and in Boston. Racism (a system of advantage) is the root cause of inequities across health outcomes and in outcomes in education, housing, food, criminal justice, and the economy. “Racism… saps the strength of the whole society through the waste of human resources." Truthfully, the existing pregnancy care system in the US is not working well for most people - from poor physical outcomes to low patient satisfaction with birthing people feeling disempowered and not well cared for. Too often the response to inequity is to create programs designed to include or accommodate “diverse” people within the existing (broken) system rather than to acknowledge that the system was only designed to serve some.

Birth equity was first defined by Dr. Joia Crear Perry and the National Birth Equity Collaborative as “the assurance of the conditions for optimal births for all people, with a willingness to address racial and social inequities in a sustained effort.” To our knowledge, few birth centers in the country have been explicitly designed to advance equity - in organizational process and in birth outcomes. Our unique focus on developing a birth center as a means of furthering social and racial justice is an innovation with the power to significantly improve health outcomes in Boston, as well as advance birth centers, midwifery, and public health towards equity.

Our History

There was an article published in 1977 in the New England Journal of Medicine called “Zones of Excess Mortality in Massachusetts” which drew attention to areas of high rates of infant mortality in the state, with a concentration in Boston’s Black neighborhoods. In September of 1990, The Boston Globe published a five part series titled “Birth in the ‘Death Zones’” pointing to the tragedy of this racial inequity in the shadow of Boston’s world renowned hospitals. This was also around the same time that at least one hospital midwifery program in Boston was eliminated.  

In response, public health officials, community health center leaders, midwives, and community organizers organized to better understand the racial inequity in birth outcomes and to develop solutions. They established the Consortium of Black Health Center Directors and also talked about a plan for a freestanding birth center in Boston.  

Political will, and pushback from insurance companies and hospitals, made it hard to move the project forward at that time. However, their tireless commitment to public health in Boston paved the way for us to revisit this idea once more. We reconvened many of these leaders in January 2015 and decided this was the right time to try again. Today, these leaders are the senior advisors for this project and their history guides this movement.

Read more about The Evolution of Maternity Care in the United States with a history of the development and rise of birth centers.