Type of Attendant at Birth by Detailed Maternal Nativity Among US-Born, Latin American and Caribbean-Born, and Sub-Saharan African-Born Black Women

Abstract

Approximately 10% of the US Black diaspora were born either in Latin America and the Caribbean (LAC) or Sub-Saharan Africa (SSA), projected to account for a third of the Black US diaspora by 2060. Yet, details on foreign-born Black women’s labor and delivery (L&D) characteristics, such as the type of birth attendant, remain scarce. We used the National Center for Health Statistics 2016 to 2020 Natality data (n = 2,041,880). The associations between detailed maternal nativity (DMN) and the type of attendant at birth (i.e., physician, certified nurse-midwife (CNM), certified professional midwife (CPM)) among US-born, LAC-born, and SSA-born Black women were examined using multivariate multinomial regression. The study revealed that LAC-born women were more likely to have a CNM during birth than US-born Black women, but Haitian-born and Jamaican-born women had lower odds of having a certified professional midwife (CPM) at birth. When compared to US-born Black women, Cameroonian-born women had decreased odds of having either a CNM or CPM during birth. Findings suggest that DMN could be an indicator of cultural preferences in maternity care. There is a need for further investigation beyond DMN and comprehensive data collection methods for future research to understand the specific needs and preferences of different ethnocultural groups to improve maternity care and prevent adverse maternal health outcomes.

1. Introduction

Between 2017 and 2019, 84% of pregnancy-related deaths in the US were preventable [1]. It is well-documented that Black women in the US are three to four times more likely to die in childbirth than their non-Black counterparts, even after adjusting for relevant social determinants of health such as age, socioeconomic status, and parity [2]. A complex interplay of factors, including systemic racism, socioeconomic barriers, lack of access to quality healthcare [3] and immigration-related disadvantages often contribute to these disparities [4,5]. However, another factor that may also contribute to these disparities is maternal nativity.

Black people are not a monolith; therefore, culture, ethnicity, and immigration characteristics must be considered in the study of Black people’s reproductive health. In 2019, 47 million people in the US identified as Black, comprising 14% of the total US population among which 4.6 million were foreign-born [5]. Among Black immigrants in the US, those who identify as Caribbean (46%) are the largest group, while Sub-Saharan African (SSA) (42%) immigrants account for the fastest growth in the Black immigrant population [6,7,8]. Notably, 42% of all Black immigrants reside in the Southern US, a region with historically limited access to maternity care and higher rates of maternal morbidity and mortality [5,9,10]. Notwithstanding their contributions to the growing US Black Diaspora, Latin American and Caribbean-born, and SSA-born women are underrepresented in current maternity research and the scientific literature.

While research has shown that Black women are at an increased risk of maternal mortality, regardless of nativity [11], disparities in maternal morbidity and mortality between US-born and foreign-born Black people are larger than nativity disparities among all other racialized populations (i.e., between US-born and foreign-born Asian populations) [12,13,14,15,16]. A review of 14 studies reported that foreign-born Black mothers had consistently lower rates of adverse birth outcomes compared to their US-born counterparts, whereas only one study revealed similar rates of adverse birth outcomes between foreign-born and US-born Black mothers [17]. A 2024 study of maternal and infant outcomes in US-born and foreign-born women revealed that, despite experiencing elevated odds of maternal morbidity, foreign-born Black women experienced lower odds of adverse birth outcomes, including low birth weight or preterm birth compared to US-born Black women [18].

In the US, the birthing process can involve a diverse group of maternity care providers, including obstetricians, family physicians, nurse-midwives, and doulas [19,20]. Midwives, particularly Certified Nurse Midwifes (CNMs), Certified Midwives (CMs) and Certified Professional Midwife (CPMs) provide comprehensive maternity and primary care [21]. However, midwifery access varies widely by state due to differences in licensure, scope of practice and regulatory environments [9,10]. As of 2023, particularly for CNMs, 3 states allow independent midwifery practice with prescribing privileges, 28 states allow independent practice, 3 states allow independent midwifery practice, 15 states require midwives to have a collaborative agreement with physicians to practice, 4 states have a hybrid model where midwives can practice independently but with restrictions, and 3 states require midwives to work under physician supervision [22]. Access to midwifery care is significantly lower in southern states which have higher rates of Black births [9,10].

The Midwifery Integration Scoring System (MISS) quantifies the integration of midwifery care and its impact, with findings suggesting that higher integration correlates with better maternal and neonatal outcomes [10,23]. These maternal outcomes include higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and the neonatal outcomes include lower rates of cesarean deliveries, preterm birth, low-birth-weight infants and neonatal deaths [10,23]. Midwifery care has also been associated with statistically significant decreased odds of having small or gestational age infants among Black Medicaid recipients in the US [24]. Racism in midwifery is a significant factor to consider in addressing maternity care inequities. Black women in the US often served as midwives, delivering babies for both enslaved and White women, until the Sheppard–Towner Act of 1921 resulted in the regulation and gradual elimination of Black midwives in the Southern US [25,26,27]. Due to higher rates of maternal mortality and morbidity and other adverse birth outcomes among women of color, Black women, in particular, have propelled interest in evidence-based models of care that can improve outcomes, that include access to midwifery care and preventive care programs developed and led by midwives [28,29].

Cultural background and beliefs can shape preferences and norms around maternity care. Mothers who are foreign-born can also face language barriers when navigating the US healthcare system, experience a lack of trust, or feel less empowered to voice concerns due to cultural differences in deference to medical authority [30]. The existing literature on associations between maternal nativity and labor and delivery (L&D) characteristics among Black women is limited. Most studies have dichotomized maternal nativity, i.e., US-born versus foreign-born, without examining associations by specific countries of birth [31,32,33,34]. Additionally, previous research primarily focused on adverse birth outcomes such as preterm birth and low birth weight [13,35,36], with limited attention to L&D care within the Black Diaspora. Specifically, how detailed maternal nativity (DMN) may influence access to and utilization of maternity care, particularly midwifery services, remains underexplored. This is an important gap given the well-established link between the type of birth attendant and birth outcomes. Associations between DMN and the type of attendant at birth may point to underlying structural barriers in healthcare access that contribute to preventable maternal morbidity and mortality. Understanding differences in the type of birth attendance by DMN can inform culturally aligned interventions aimed at improving Black maternal and neonatal health.

This study aimed to address the gaps in the existing literature by examining associations between DMN (i.e., mother’s specific country of birth) and the type of attendant at birth among US-born, LAC-born, and SSA-born Black women in the US who had a birth between 2016 and 2020. We sought to assess differences in the type of attendant at birth between LAC-born and SSA-born Black mothers in comparison to US-born Black mothers. Due to the lack of access to midwifery care in states with higher rates of Black births [10], it was hypothesized that LAC-born and Sub-Saharan Africa (SSA)-born women would have lower odds of being attended by midwives compared to their US-born counterparts.

2. Materials and Methods

2.1. Data Source

The Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) collaborates with states to collect and publish data on vital statistics, including all US live births, death certificates, and fetal death reports [37]. Birth certificate data, often referred to as natality data, records births within the US, covering US citizens, residents, and non-residents. Public-use natality data, micro-data files, are available on the NCHS website [37]. However, due to confidentiality concerns, specific geographic data such as the state of residence or maternal country of birth are restricted [38]. To study the associations between DMN and the type of attendant at birth, access to the all-county restricted micro-data natality files for 2016–2020 was secured from NCHS.

2.2. Ethics

The UNC Charlotte Institutional Review Board (IRB) deemed this study exempt from needing IRB approval as there was no human participation. Following the submission of a brief proposal of research objectives and a data security plan, NCHS granted access to the datasets.

2.3. Study Design and Population

The initial sample included non-Hispanic Black adult women of reproductive age (20–49) [14], who had a singleton birth in the US between 2016 and 2020 (n = 2,556,727). Women who had missing data on their nativity status (n = 9085), were non-US residents (n = 2558), were born in regions other than the US, the LAC, or SSA (n = 31,696), or did not have a singleton delivery (n = 108,428) were excluded. Women who had missing or incomplete information on the following independent variables were also excluded: US region of residence (n = 91,063), marital status (n = 80,157), mother’s education (n = 16,400), parity (n = 7582), BMI (n = 67,788), method of delivery (n = 773), prenatal care adequacy (n = 80,709), or previous cesarean (n = 1206). Lastly, women whose place of delivery was unknown (n = 1674), and women whose attendant at birth was listed as “other” or “unknown” (n = 15,728) were excluded. The final sample included 2,041,880 deliveries.

2.4. Study Variables

The main exposure in this study was DMN, i.e., the mother’s region and country of birth (

Table 1. Frequencies of US-born, Latin American and Caribbean-born (LAC), and Sub-Saharan African (SSA)-born Black Women, 2016–2020 NCHS Natality Data.

Mother’s Birth Country	N	%
US	1,732,603	(84.85)
Latin America and Caribbean
Anguilla	68	(0.00)
Antigua Barbuda	446	(0.02)
Aruba	20	(0.00)
Barbados	569	(0.03)
Belize	540	(0.03)
Brazil	1005	(0.05)
Cayman Islands	78	(0.00)
Columbia	73	(0.00)
Cuba	80	(0.00)
Dominican Republic	1070	(0.05)
Ecuador	43	(0.00)
El Salvador	150	(0.01)
Grenada	523	(0.02)
Guadeloupe	72	(0.00)
Guatemala	255	(0.01)
Guyana	3347	(0.16)
Haiti	51,948	(2.54)
Jamaica	31,112	(1.52)
Martinique	28	(0.00)
Nicaragua	49	(0.00)
Panama	315	(0.02)
Peru	33	(0.00)
Saint Lucia	702	(0.03)
The Bahamas	2908	(0.14)
Trinidad and Tobago	4236	(0.21)
Turks & Caicos Islands	233	(0.01)
Venezuela	92	(0.00)
Other LAC Countries	46	(0.00)
Sub-Saharan Africa
Angola	873	(0.04)
Benin	860	(0.04)
Botswana	118	(0.01)
Burkina Faso	1089	(0.05)
Burundi	1476	(0.07)
Cameroon	9725	(0.48)
Cape Verde	3415	(0.16)
Central African Republic	292	(0.01)
Chad	269	(0.01)
Congo	3347	(0.16)
Democratic Republic of Congo (DRC)	11,039	(0.52)
Côte D’Ivoire	2780	(0.14)
Djibouti	479	(0.02)
Equatorial Guinea	203	(0.01)
Eritrea	4429	(0.23)
Ethiopia	29,322	(1.46)
Gabon	398	(0.02)
Gambia	1807	(0.09)
Ghana	17,233	(0.83)
Guinea-Bissau	68	(0.00)
Kenya	13,143	(0.64)
Kingdom of eSwatini	33	(0.00)
Lesotho	27	(0.00)
Liberia	10,021	(0.49)
Madagascar	79	(0.00)
Malawi	328	(0.02)
Mali	1177	(0.06)
Mozambique	85	(0.00)
Niger	530	(0.03)
Nigeria	42,497	(2.11)
Rwanda	1480	(0.07)
Senegal	2800	(0.14)
Sierra Leone	3938	(0.19)
Somalia	26,422	(1.29)
South Africa	941	(0.05)
SU Sudan	6793	(0.33)
Tanzania	1843	(0.09)
Togo	3066	(0.15)
Uganda	2654	(0.14)
Zambia	814	(0.04)
Zimbabwe	1200	(0.06)
Other SSA Countries	44	(0.00)

Countries with more than 5000 observations are bolded.

). The mother’s detailed nativity was determined by the birth country variable available on the child’s Birth Certificate Record. Black women who indicated being born in the LAC, or sub-Saharan Africa were compared to US-born Black women who were the reference group. Individual countries with lower than 5000 observations were collapsed into two composite variables called “All Other” for the LAC and SSA, respectively [16,39]. The outcome measure was the type of attendant at birth (i.e., physician, certified nurse midwife (CNM), or other midwife (CPM)). Information on the attendant at birth is abstracted from the medical record and recorded in standardized fields on the birth certificate [40].

The covariates included maternal age (20–29, 30–39, 40–49), mother’s education (some high school, high school graduate, some college, college degree, or unknown), marital status (married or unmarried), parity (1, 2, ≥3), gestational weight gain (according to the Institute of Medicine guidelines) [41], adequacy of prenatal care (adequate, intermediate, or inadequate), previous cesarean delivery, insurance type, US region of residence (Northeast, Midwest, South or West), location of residence (urban vs. rural), and scope of CNM practice per state (collaborative agreement, independent practice with prescribing privileges, independent practice, hybrid model, and physician supervision required) [42]. Prenatal care adequacy was measured using the Adequacy of Prenatal Care Utilization Index [38,39]. The month prenatal care began and the number of prenatal care visits variables were used to create the following categories: Adequate = began care between 1 and 4 months, and had at least 15 prenatal visits at 40 weeks, Intermediate = began care between 1 and 4 months and had ≤11 prenatal visits, and Inadequate = began care at or after the 5th month, and had ≤6 prenatal visits [43].

2.5. Statistical Analysis

LAC-born and SSA-born women were compared to US-born Black women. Comparisons were also made between LAC-born and SSA-born Black women and by maternal country of birth within the LAC and within SSA countries (e.g., Haiti vs. All Other LAC, Nigeria vs. All Other SSA) [39]. To describe the sample, univariate analyses were conducted using frequencies for categorical variables and group differences were tested using Pearson Chi-square tests. Unadjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using multinomial regression to obtain the crude association between DMN and the type of attendant at birth. Multivariate multinomial regression models were used to obtain adjusted odds ratios and 95% confidence intervals for the association between DMN and the type of attendant at birth while controlling for potential confounders. Variables that changed the crude odds ratio estimates by a minimum of 10% were included in the multivariate models [44]. The final model was adjusted for age, marital status, education, insurance, and region of residence in the US; All analyses were conducted in SAS software version 9.4 [45].

3. Results

Approximately 85% of the Black women who had a singleton delivery between 2016 and 2020 were US-born and 15% were foreign-born (Table 1). Of the foreign-born women, 10.24% were from SSA, and 4.87% were from LAC (

Table 2. Comparison of Demographic Characteristics of Latin American and Caribbean-born (LAC) Black women by country of birth, 2016–2020 NCHS Natality Data.

Variables	Haiti	Jamaica	All Other LAC	p Value a
	n = 51,948 (2.54)	n = 31,112 (1.52)	n = 16,981 (0.83)
Maternal Age				<0.0001
20–29	17,907 (0.88)	11,768 (0.58)	5840 (0.29)
30–39	29,214 (1.43)	29,214 (0.82)	9815 (0.48)
40–49	4827 (0.24)	2666 (0.13)	1326 (0.06)
Marital Status				<0.0001
Married	34,402 (1.68)	17,037 (0.83)	10,112 (0.50)
Not Married	17,546 (0.86)	14,075 (0.69)	6869 (0.34)
Mother’s Education				<0.0001
Less Than High School	7754 (0.38)	1370 (0.07)	986 (0.05)
High School or GED	18,347 (0.90)	8644 (0.42)	4534 (0.22)
Some College or College Degree	23,614 (1.16)	17,609 (0.86)	8966 (0.44)
Graduate Degree	2233 (0.11)	3489 (0.17)	2495 (0.12)
Parity				<0.0001
1	17,242 (0.84)	11,889 (0.58)	6363 (0.31)
2	16,705 (0.82)	10,261 (0.50)	5699 (0.28)
≥3	18,001 (0.88)	8962 (0.44)	4919 (0.24)
Gestational Weight Gain				<0.0001
Met	15,749 (0.77)	9202 (0.45)	5169 (0.25)
Below	16,178 (0.79)	6885 (0.34)	4126 (0.20)
Exceeded	20,021 (0.98)	15,025 (0.74)	7686 (0.38)
Prenatal Care Adequacy				<0.0001
Adequate	32,140 (1.57)	20,928 (1.02)	11,115 (0.54)
Intermediate	6672 (0.33)	3602 (0.18)	2063 (0.10)
Inadequate	13,136 (0.64)	6582 (0.32)	3803 (0.19)
Insurance Type				<0.0001
Medicaid	30,047 (1.47)	12,782 (0.63)	6261 (0.31)
Private	14,690 (0.72)	13,867 (0.68)	7971 (0.39)
Self-Pay	5384 (0.26)	2801 (0.14)	1831 (0.09)
Other	1827 (0.09)	1662 (0.08)	918 (0.04)
Region of Residence				<0.0001
Northeast	15,911 (0.78)	11,668 (0.57)	5234 (0.26)
Midwest	1562 (0.08)	1413 (0.07)	859 (0.04)
South	33,933 (1.66)	17,353 (0.85)	10,258 (0.50)
West	542 (0.03)	678 (0.03)	630 (0.03)
Location of Residence				<0.0001
Urban	51,938 (2.54)	17 (1.52)	16,946 (0.83)
Rural	10 (0.00)	31,095 (0.00)	35 (0.00)
Previous Cesarean				<0.0001
Yes	10,201 (0.50)	4802 (0.24)	3010 (0.15)
No	41,747 (2.04)	26,310 (1.29)	13,971 (0.68)
Attendant Type				<0.0001
Physician/Doctor	44,393 (2.17)	27,510 (1.35)	15,169 (0.74)
Certified Nurse-Midwife (CNM)	7297 (0.36)	3444 (0.17)	1678 (0.08)
Other Midwife (CPM)	258 (0.01)	158 (0.01)	134 (0.01)
Place of Birth				<0.0001
Hospital	51,755 (0.82)	30,921 (2.53)	16,814 (2.53)
Freestanding Birthing Center	86 (0.00)	94 (0.00)	95 (0.00)
Home (intended)	87(0.00)	80 (0.00)	65 (0.00)
Home (not intended)	20 (0.00)	17 (0.00)	7 (0.00)
Method of Delivery				<0.0001
Vaginal	30,667 (1.50)	19,256 (0.94)	10,437 (0.51)
Cesarean	21,281 (1.04)	11,856 (0.58)	6544 (0.32)

^a p values refer to a Pearson Chi-square test for the differences by maternal country of birth.

and

Table 3. Comparison of Demographic Characteristics of Sub-Saharan African (SSA)-born Black women by country of birth, 2016–2020 NCHS Natality Data.

Variables	Cameroon	DRC	Ethiopia	Kenya	Liberia	Ghana	Nigeria	Sudan	Somalia	All Other SSA	p Value a
	n = 9725 (0.48)	n = 11,039 (0.54)	n = 29,322 (1.44)	n = 13,143 (0.64)	n = 10,021 (0.49)	n = 17,233 (0.84)	n = 42,497 (2.08)	n = 6793 (0.33)	n = 26,422 (1.29)	n = 43,041 (2.11)
Maternal Age											<0.0001
20–29	3614 (0.18)	5393 (0.26)	8977 (0.44)	5612 (0.27)	4255 (0.21)	4516 (0.22)	10,404 (0.51)	2378 (0.12)	9727 (0.48)	16,894 (0.83)
30–39	5568 (0.27)	5090 (0.25)	18,261 (0.89)	6507 (0.32)	5286 (0.26)	11,414 (0.56)	29,109 (1.43)	3870 (0.19)	15,223 (0.75)	23,130 (1.13)
40–49	543 (0.03)	556 (0.03)	2084 (0.10)	1024 (0.05)	480 (0.02)	1303 (0.06)	2984 (0.15)	545 (0.03)	1472 (0.07)	3017 (0.15)
Marital Status											<0.0001
Married	7204 (0.35)	8358 (0.41)	20,726 (1.02)	9304 (0.46)	5283 (0.26)	12,860 (0.63)	36,809 (1.80)	5568 (0.27)	20,147 (0.99)	30,207 (1.48)
Not Married	2521 (0.12)	2681 (0.13)	8596 (0.42)	3839 (0.19)	4738 (0.23)	4373 (0.21)	5688 (0.28)	1225 (0.06)	6275 (0.31)	12,834 (0.63)
Mother’s Education											<0.0001
Less Than High School	293 (0.01)	3008 (0.15)	4852 (0.24)	987 (0.05)	1078 (0.05)	486 (0.02)	902 (0.04)	1336 (0.07)	12,932 (0.63)	7658 (0.38)
High School or GED	1490 (0.07)	4040 (0.20)	9131 (0.45)	2568 (0.13)	3585 (0.18)	3402 (0.17)	4678 (0.23)	1749 (0.09)	7075 (0.35)	11,224 (0.55)
Some College or College Degree	6101 (0.30)	3696 (0.18)	13,661 (0.67)	7946 (0.39)	4865 (0.24)	10,376 (0.51)	26,415 (1.29)	3232 (0.16)	6084 (0.30)	19,885 (0.97)
Graduate Degree	1841 (0.09)	295 (0.01)	1678 (0.08)	1642 (0.08)	493 (0.02)	2969 (0.15)	10,502 (0.51)	476 (0.02)	331 (0.02)	4274 (0.21)
Parity											<0.0001
1	3392 (0.17)	3051 (0.15)	9527 (0.47)	402 (0.23)	2532 (0.12)	5665 (0.28)	14,413 (0.71)	1445 (0.07)	3804 (0.19)	14,124 (0.69)
2	3123 (0.15)	2686 (0.13)	9968 (0.49)	4436 (0.22)	2934 (0.14)	5734 (0.28)	13,700 (0.67)	1532 (0.08)	4145 (0.20)	13,237 (0.65)
≥3	3210 (0.16)	5302 (0.26)	9827 (0.48)	4005 (0.20)	4555 (0.22)	5834 (0.29)	14,384 (0.70)	3816 (0.19)	18,473 (0.90)	15,680 (0.77)
Gestational Weight Gain											<0.0001
Met	2769 (0.14)	3399 (0.17)	10,192 (0.50)	4318 (0.21)	2898 (0.14)	5374 (0.26)	13,504 (0.66)	2049 (0.10)	7915 (0.39)	13,287 (0.65)
Below	1826 (0.09)	3785 (0.19)	8733 (0.43)	4157 (0.20)	2579 (0.13)	4349 (0.21)	10,610 (0.52)	2623 (0.13)	11,451 (0.56)	13,300 (0.65)
Exceeded	5130 (0.25)	3855 (0.19)	10,397 (0.51)	4668 (0.23)	4544 (0.22)	7510 (0.37)	18,383 (0.90)	2121 (0.10)	7056 (0.35)	16,454 (0.81)
Prenatal Care Adequacy											<0.0001
Adequate	6298 (0.31)	6178 (0.30)	18,056 (0.88)	8271 (0.41)	6629 (0.32)	11,939 (0.58)	21,994 (1.08)	4098 (0.20)	15,000 (0.73)	26,387 (1.29)
Intermediate	1001 (0.05)	1025 (0.05)	3637 (0.18)	1645 (0.08)	1255 (0.06)	1788 (0.09)	3747 (0.18)	820 (0.04)	4508 (0.22)	4557 (0.22)
Inadequate	2426 (0.12)	3836 (0.19)	7629 (0.37)	3227 (0.16)	2137 (0.10)	3506 (0.17)	16,756 (0.82)	1875 (0.09)	6914 (0.34)	12,097 (0.59)
Insurance Type											<0.0001
Medicaid	4662 (0.23)	7409 (0.36)	16,647 (0.82)	5837 (0.29)	5442 (0.27)	6786 (0.33)	13,668 (0.67)	4138 (0.20)	21,734 (1.06)	22,650 (1.11)
Private	3994 (0.20)	2440 (0.12)	10,729 (0.53)	6030 (0.30)	3718 (0.18)	8385 (0.41)	14,307 (0.70)	2090 (0.10)	430 (0.19)	15,320 (0.75)
Self-Pay	545 (0.03)	926 (0.05)	989 (0.05)	705 (0.03)	436 (0.02)	1139 (0.06)	12,501 (0.61)	369 (0.02)	3830 (0.02)	3005 (0.15)
Other	524 (0.03)	264 (0.01)	957 (0.05)	571 (0.03)	425 (0.02)	923 (0.05)	2021 (0.10)	196 (0.01)	428 (0.02)	2066 (0.10)
Region of Residence											<0.0001
Northeast	1170 (0.06)	1522 (0.07)	2865 (0.14)	2223 (0.11)	2737 (0.13)	5365 (0.26)	6106 (0.30)	947 (0.05)	2009 (0.10)	10,911 (0.53)
Midwest	1670 (0.08)	3397 (0.17)	7803 (0.38)	4250 (0.21)	3970 (0.19)	3382 (0.17)	6709 (0.33)	2332 (0.11)	18,126 (0.89)	10,143 (0.50)
South	6392 (0.31)	4376 (0.21)	12,800 (0.63)	4852 (0.24)	2726 (0.13)	7548 (0.37)	27,830 (1.36)	2540 (0.12)	2713 (0.13)	17,704 (0.87)
West	493 (0.02)	1744 (0.09)	5854 (0.29)	1818 (0.09)	588 (0.03)	938 (0.05)	1852 (0.09)	974 (0.05)	3574 (0.18)	4283 (0.21)
Location of Residence											<0.0001
Urban	9724 (0.48)	11,010 (0.54)	29,312 (1.44)	13,129 (0.64)	10,013 (0.49)	17,221 (0.84)	42,481 (2.08)	6791 (0.33)	26,419 (1.29)	43,006 (2.11)
Rural	1 (0.00)	29 (0.00)	10 (0.00)	14 (0.00)	8 (0.00)	12 (0.00)	16 (0.00)	2 (0.00)	3 (0.00)	35 (0.00)
Previous Cesarean											<0.0001
Yes	1895 (0.09)	1872 (0.09)	6893 (0.34)	2543 (0.12)	2069 (0.10)	4156 (0.20)	9124 (0.45)	1573 (0.08)	6121 (0.30)	8046 (0.39)
No	7830 (0.38)	9167 (0.45)	22,429 (1.10)	10,600 (0.52)	7952 (0.39)	13,077 (0.64)	33,373 (1.63)	5220 (0.26)	20,301 (0.99)	34,995 (1.71)
Attendant Type											<0.0001
Doctor	9084 (0.44)	9968 (0.49)	26,583 (1.30)	11,728 (0.57)	8978 (0.44)	15,880 (0.78)	39,851 (1.95)	6191 (0.30)	21,844 (1.07)	38,365 (1.88)
CNM	613 (0.03)	1024 (0.05)	2690 (0.13)	1354 (0.07)	1014 (0.05)	1316 (0.06)	2425 (0.12)	578 (0.03)	4545 (0.22)	4398 (0.22)
CPM	28 (0.00)	47 (0.00)	49 (0.00)	61 (0.00)	29 (0.00)	37 (0.00)	221 (0.01)	24 (0.00)	33 (0.00)	278 (0.01)
Place of Birth											<0.0001
Hospital	9703 (0.48)	11,026 (0.54)	29,274 (1.43)	13,081 (0.64)	10,001 (0.49	17,186 (0.84)	42,236 (2.07)	6776 (0.33)	26,387 (1.29)	42,886 (2.10)
Freestanding Birthing Center	12 (0.00)	4 (0.00)	23 (0.00)	32 (0.00)	12 (0.00)	20 (0.00)	181 (0.01)	8 (0.00)	14 (0.00)	68 (0.00)
Home (intended)	7 (0.00)	3 (0.00)	10 (0.00)	23 (0.00)	6 (0.00)	11 (0.00)	66 (0.00)	4 (0.00)	7 (0.00)	58 (0.00)
Home (not intended)	3 (0.00)	6 (0.00)	15 (0.00)	7 (0.00)	(0.00)	16 (0.00)	14 (0.00)	5 (0.00)	14 (0.00)	29 (0.00)
Method of Delivery											<0.0001
Vaginal	5944 (0.29)	7601 (0.37)	17,293 (0.85)	8151 (0.40)	6229 (0.31)	9892 (0.48)	24,684 (1.21)	4626 (0.23)	19,940 (0.98)	28,260 (1.38)
Cesarean	3781 (0.19)	3438 (0.17)	12,029 (0.59)	4992 (0.24)	3792 (0.19)	7341 (0.36)	17,813 (0.87)	2167 (0.11)	6482 (0.32)	14,781 (0.72)

^a p values refer to a Pearson Chi-square test for the differences by maternal country of birth.

), with the highest number of births among them from women born in Nigeria and Haiti. The overall geographic distribution was predominantly in the Southern US. Most US-born Black women giving birth were aged 20–29 (55.50%), 44.78% had some level of higher education, and 63.80% were unmarried. Among foreign-born Black women, most were in the 30–39 age group (8.85%), 9.19% had some level of higher education, and 4.58% were unmarried. In the overall sample, 64.07% of the deliveries were covered by Medicaid. A total of 91% of all deliveries were attended by a physician, and less than 1% occurred in out-of-hospital settings.

Overall, LAC-born Black women had increased odds of having either a CNM or a CPM at delivery compared to women who were attended by physicians. and these findings were statistically significant (ORs ranged from 1.30 to 2.31) (

Table 4. Unadjusted odds ratios and 95% confidence intervals for the association between detailed maternal nativity and attendant at birth.

Attendant at Birth (Reference Physician)
Variables	Unadjusted ORs
	Certified Nurse-Midwife (CNM)	Other Midwife (CPM)
	OR (95% CI)	OR (95% CI)
Mothers’ Nativity
Born in US	1.00 (Referent)	1.00 (Referent)
Foreign-Born	1.39 (1.37–1.41)	1.29 (1.22–1.37)
Mother’s Birth Country
US	1.00 (Referent)	1.00 (Referent)
Latin America and Caribbean
Haiti	1.94 (1.89–1.99)	1.52 (1.34–1.72)
Jamaica	1.47 (1.42–1.53)	1.50 (1.28–1.75)
All Other LAC	1.30 (1.24–1.37)	2.31 (1.94–2.74)
Sub-Saharan Africa
Cameroon	0.80 (0.73–0.86)	0.80 (0.55–1.17)
DRC	1.21 (1.13–1.30)	1.23 (0.92–1.64)
Ethiopia	1.21 (1.13–1.30)	1.23 (0.92–1.64)
Ghana	1.19 (1.15–1.24)	0.48 (0.36–0.64)
Kenya	0.98 (0.92–1.03)	0.61 (0.44–0.84)
Liberia	1.36 (1.29–1.44)	1.36 (1.05–1.75)
Nigeria	1.33 (1.25–1.42)	0.84 (0.58–1.21)
Somalia	0.72 (0.69–0.75)	1.45 (1.26–1.65)
Sudan	2.45 (2.37–2.53)	0.39 (0.28–0.56)
All Other SSA	1.09 (1.01–1.19)	1.01 (0.68–1.51)
Maternal Age
20–29	1.00 (Referent)	1.00 (Referent)
30–39	0.85 (0.84–0.86)	1.19 (1.14–1.25)
40–49	0.65 (0.62–0.67)	0.80 (0.69–0.93)
Marital Status
Married	1.17 (1.16–1.18)	2.46 (2.35–2.57)
Not Married	1.00 (Referent)	1.00 (Referent)
Mother’s Education
Less Than High School	1.07 (1.05–1.09)	0.34 (0.30–0.38)
High School or GED	1.01 (1.00–1.10)	0.48 (0.45–0.50)
Some College or College Degree	1.00 (Referent)	1.00 (Referent)
Graduate Degree	0.87 (0.85–0.89)	1.41 (1.31–1.51)
Parity
1	0.99 (0.98–1.00)	1.05 (1.00–1.11)
2	1.01 (1.00–1.02)	0.99 (0.93–1.04)
≥3	1.00 (Referent)	1.00 (Referent)
Gestational Weight Gain
Met	1.01 (1.09–1.12)	1.14 (1.08–1.20)
Below	1.07 (1.06–1.08)	0.85 (0.80–0.90)
Exceeded	1.00 (Referent)	1.00 (Referent)
Prenatal Care Adequacy
Adequate	1.00 (Referent)	1.00 (Referent)
Intermediate	1.14 (1.12–1.16)	0.89 (0.83–0.96)
Inadequate	1.07 (1.06–1.08)	1.12 (1.07–1.19)
Insurance Type
Medicaid	1.00 (Referent)	1.00 (Referent)
Private	0.92 (0.91–0.93)	1.18 (1.11–1.25)
Self-Pay	1.21 (1.18–1.25)	14.15 (13.36–14.98)
Other	1.70 (1.65–1.73)	2.42 (2.19–2.68)
Region of Residence
Northeast	1.61 (1.59–1.63)	0.58 (0.54–0.63)
Midwest	1.20 (1.18–1.21)	0.37 (0.34–0.40)
West	1.77 (1.73–1.81)	1.08 (0.98–1.19)
South	1.00 (Referent)	1.00 (Referent)
Location of Residence
Urban	1.00 (Referent)	1.00 (Referent)
Rural	0.60 (0.55–0.65)	0.37 (0.22–0.63)
Previous Cesarean
Yes	0.16 (0.16–0.17)	0.18 (0.16–0.20)
No	1.00 (Referent)	1.00 (Referent)
CNM Scope of Practice/State
Collaborative Agreement	1.00 (Referent)	1.00 (Referent)
Independent Practice and Privileges	2.88 (2.77–2.99)	1.16 (0.93–1.44)
Independent Practice	1.96 (1.94–1.99)	0.82 (0.77–0.87)
Hybrid Model	2.45 (2.41–2.49)	3.11 (2.94–3.29)
Physician Supervision Required	2.33 (2.30–2.36)	0.83 (0.77–0.90)

p value < 0.05.

). Among SSA-born women, Cameroonian-born Black women had decreased odds of having either a CNM (OR = 0.80; 95% CI: 0.73–0.86), or a CPM (OR = 0.80; 95% CI: 0.55–1.17) compared to US-born Black women. Ghanaian-born and Nigerian-born women had increased odds of having a CNM at delivery (OR(G) = 1.19; 95% CI: 1.15–1.24) and OR(N) = 1.33; 95% CI: 1.25–1.42), respectively, but decreased odds of having a CPM (OR(G) = 0.48; 95% CI: 0.36–0.64) and OR(N) = 0.84; 95% CI: 0.58–1.21), respectively, compared to US-born Black women.

After adjusting for age, marital status, education, insurance, and region of residence in the US, and CNM scope of practice by state, the associations between DMN and attendant at birth remained statistically significant in several cases, though some estimates were attenuated. Among LAC-born women, Haitian-born women had 36% higher odds of having a CNM-attended birth (OR = 1.36; 95% CI: 1.32–1.40) and Jamaican-born women had increased odds of CNM-attended birth (OR = 1.01; 95% CI: 1.06–1.14) compared to US-born women, as well as significantly decreased odds of CPM attendance (OR = 0.39; 95% CI: 0.33–0.46) (

Table 5. Adjusted odds ratios and 95% confidence intervals for the association between detailed maternal nativity and attendant at birth.

Attendant at Birth (Reference Physician)
	Unadjusted ORs
Mother’s Birth Country	Certified Nurse-Midwife (CNM)	Other Midwife (CPM)
	OR (95% CI)	OR (95% CI)
US	1.00 (Referent)	1.00 (Referent)
Latin America and Caribbean
Haiti	1.36 (1.32–1.40)	0.28 (0.24–0.32)
Jamaica	1.01 (1.06–1.14)	0.39 (0.33–0.46)
All Other LAC	1.05 (0.99–1.10)	0.53 (0.44–0.64)
Sub-Saharan Africa
Cameroon	0.80 (0.74–0.87)	0.34 (0.23–0.50)
DRC	1.00 (0.94–1.07)	0.61 (0.46–0.82)
Ethiopia	1.04 (1.00–1.08)	0.35 (0.27–0.47)
Ghana	0.88 (0.83–0.93)	0.26 (0.19–0.37)
Kenya	1.17 (1.11–1.24)	0.72 (0.56–0.94)
Liberia	1.12 (1.05–1.20)	0.69 (0.47–0.99)
Nigeria	0.73 (0.70–0.76)	0.16 (0.14–0.19)
Somalia	1.95 (1.88–2.02)	0.59 (0.41–0.83)
Sudan	0.88 (0.81–0.96)	0.53 (0.35–0.80)
All Other SSA	1.16 (1.12–1.20)	0.95 (0.84–1.08)

Model adjusted for age, marital status, education, insurance, and region of residence, and CNM scope of practice in the US. p value < 0.05.

). Among SSA-born women, the odds of CNM-attended births were significantly higher for women born in Kenya, Liberia, Somalia and those in the “All Other SSA” category (ORs ranging from 1.12 to 1.95), while Ghanaian-born and Nigerian-born women now had significantly decreased odds of having a CNM at delivery (OR(G) = 0.88; 95% CI: 0.83–0.93)) and (OR(N) = 0.73; 95% CI: 0.70–0.76), respectively. The associations observed among Cameroonian-born women continued to demonstrate statistically significant decreased odds of having either a CNM or CPM at delivery compared to women who had physician-attended births; however, findings were attenuated after adjustment. Both LAC-born and SSA-born women had statistically significant decreased odds of having CPM-attended births (ORs ranging from 0.16 to 0.95).

4. Discussion

This study explored the associations between DMN and the type of attendant at birth among US-born, LAC-born, and SSA-born Black women who had a delivery in the US between 2016 and 2020. Contrary to the initial hypotheses, findings revealed that, after adjusting for age, marital status, education, insurance status, region of residence in the US, and CNM scope of practice, LAC-born women generally had increased odds of being attended by a CNM at delivery compared to US-born women. In contrast, all foreign-born women had decreased odds of being attended by a CPM, supporting our hypotheses. SSA-born women, particularly women from Cameroon, Ghana, Kenya, Liberia, Nigeria, and Somalia, exhibited varying associations for the odds of being attended by a CNM. Cameroonian, Ghanaian, and Nigerian-born women had decreased odds of having a CNM at delivery. In contrast, Kenyan, Liberian, and Somalian-born women had increased odds of being attended by a CNM. These findings align with previous research which showed notable differences in L&D characteristics, including the place and method of delivery by DMN across the US Black diaspora [46].

To our knowledge, this is the first study to examine the association between DMN and the type of attendant at birth among a nationally representative sample of US-born, SSA-born, and LAC-born Black mothers. However, previous research which can help contextualize the current findings has examined associations between maternal nativity and L&D practices [47], as well as the association between racial segregation and adverse birth outcomes including preterm birth and low birth weight [48]. In a 2022 study of Black mothers in New York City (N = 135,701), authors found differences in the incidence of low birth weight and preterm births, with the lowest rates among African-born and LAC-born Black mothers when compared to US-born Black mothers. It is possible that the mechanisms influencing differences in birth outcomes by nativity, such as cultural norms, could also influence the association between DMN and the type of attendant at birth [39,48]. Foreign-born people, especially recent immigrants (i.e., five years or less) often face barriers to accessing health insurance and care [19]. Insurance reimbursement policies may influence access to midwifery care and by extension the likelihood of being attended by a midwife. While Medicaid does cover CNM services, reimbursement for CPM services vary widely across states [49]. In our analysis, compared to Medicaid, private insurance was associated with lower odds of any midwife-attended births, while self-pay was associated with significantly higher odds of CPM-attended births (see Supplementary File, Table S2).

4.1. Limitations and Strengths

This study has several limitations. One limitation is the potential for nondifferential misclassification, particularly regarding the type of birth attendant. Previous research suggests that midwife-attended birth numbers might be underreported on birth certificates, especially when multiple providers are present or when hospitals mandate listing a physician as the primary attendant, regardless of their physical presence at midwife-attended births [50,51,52]. Thus, findings may be biased toward the null. Findings may have also been influenced by health selection bias. Health selection refers to the degree to which potential immigrants migrate or not based on their health status [53]. Specifically, Sub-Saharan African women might be more likely to migrate to the US based on their positive health status, complicating interpretations of our findings. Previous research has shown that African immigrants were 81% more likely to report having excellent health prior to immigrating to the US [53]. Additionally, this secondary data analysis was limited by the data collected on the birth certificates. Thus, confounding due to a variable not collected on birth certificates (e.g., length of stay in the US) is possible.

Despite these limitations, this study had several strengths. First, the impact of DMN on the type of attendant at birth is under-researched and previous studies have typically dichotomized nativity status (US vs. foreign-born). One prospective antenatal survey study published in 2010 assessed preferences in L&D practices (including method of delivery, choice of pain relief, place of delivery, position, and mobility in labor) between pregnant Somali and Sudanese immigrants and US-born women (N = 93) receiving care at a family practice in New York [47]. The results indicated differences in L&D preferences between US-Born and foreign-born women; however, most were not statistically significant and the authors did not differentiate between White and Black US-born women [47]. In contrast, this study used a race-concordant sample in addition to the granular approach to nativity status and examined specific maternal countries of origin within the two regions contributing the highest number of Black immigrants in the US. This level of detail allows for more nuanced insights and helps to reduce overgeneralizations since Black women are not a monolith. Another of this study’s strengths is our use of natality US birth certificate data across all 50 states, enhancing the generalizability of the findings to US-born, SSA-born, and LAC-born Black mothers who delivered in the US between 2016 and 2020. The study’s large sample size also addresses the limitations of previous studies that were limited by small samples.

4.2. Implications

These findings highlight the need for more nuanced research and healthcare policies that consider the specific needs and preferences of different groups of pregnant women based on their ethnocultural origins. The significant changes in some associations after adjustment suggest that immigrant Black women’s use of midwifery in US births is a combination of cultural preference, financial costs of labor and delivery, and structural availability of midwifery care. Public health interventions may need to account for these factors to be effective. For example, efforts to increase access to midwifery care should include support for building and diversifying the midwifery workforce, especially given that states with higher proportions of Black births have the lowest midwifery integration scores in the country [10]. Such efforts should also include providing education about the history and benefits of midwifery care and considering cost coverage for US-born and foreign-born Black women. Different cultural backgrounds might contribute to the differences in the type of attendant-at-birth characteristics we observed. Understanding the unique needs and experiences of US-born and foreign-born Black women can lead to improved quality of maternity care, patient satisfaction, and potentially eradicate preventable adverse maternal health outcomes. It is therefore crucial for providers to be able to consider nativity and cultural preferences regarding maternity care to assess, recognize, and respect Black women’s L&D needs.

5. Conclusions

While we observed some trends consistent with our hypotheses, there were notable exceptions that warrant further investigation. Future studies should continue to challenge the oversimplification of Black maternal health outcomes by focusing on more comprehensive data collection methods such as qualitative and mixed-methods research to delve deeper into the underlying mechanisms for the observed differences in the type of attendant at birth, as well as patient–provider interactions, quality of care, social determinants of health, and immigration-related stressors across the US Black diaspora.