Policy and Demographic Considerations for LGBTQIA Families and Midwives

Midwives who either are themselves lesbian, gay, bisexual, transgender, queer or questioning, intersex, two spirit or other aligned identities (LGBTQI2S+) or want to serve the LGBTQI2S+ community have to consider both the policy environment for the practice of midwifery and the policy environment for LGBTQI2S+people. This write-up provides an initial and novel analysis of data about midwifery integration and LGBTQI2S+ equality. There are some great tools available to address these issues. We hope to bring them all together for the first time here. 

The Birth Place Lab created an interactive map based on their paper “Mapping integration of midwives across the United States: Impact on access, equity, and outcomes.” The maps can be accessed at: https://www.birthplacelab.org/maps/ 

Using the “Integration” tab on the map, you can quickly get a sense of where midwifery is most integrated and where it is least integrated. There are four levels of integration on the map. You can also click on each state to get some more details or to see how integration relates to birth outcomes. For even more information they have created a “report card” for each state. The report cards include five components of midwifery integration for the CNM, CPM and CM credentials including whether that credential is licensed, covered by Medicaid, authorized to write prescriptions, has easy access to physician referral, and no restrictions on site of practice. 

Integration is “scored” on a scale of 1-100. Even the state with the best midwifery integration score (Washington) has room for improvement (they have a score of 61 out of 100). But even the lower scoring states (like North Carolina with 17 out of 100) are worth taking a closer look at to learn for example, that the percent of births attended by midwives there is higher than the national average (13.4% versus 10.3%) and higher than other states with more midwifery integration like Missouri which scores 39 out of 100 but where midwives attend only 4.4% of births. Seven states in the West and Northwest are in the highest category of integration, with five in the Northeast and one in the Midwest. But there are thirteen states in the second-highest range spread across the country. 

There is also a “Density” tab on the map, that illustrates where there are more and less midwives in the country which can be further distinguished by CNM/CM versus CPM. Right below that is the “Access to Place of Birth” tab that illustrates access based on the relative amount of community birth in each state, which can then be distinguished based on home or birth center, and CNM/CM and all other midwives. Together, the “Density” tab and the “Access to Place of Birth” tabs provide a view of where midwives are across the country.

There are twenty states that meet the two highest levels of midwife-density, but only four of those have the highest levels, Vermont, Oregon, Maine and Alaska. Of those, Vermont, Oregon and Maine have high rates of CPMs, while Alaska has higher CNM density. Of course, more midwives are needed everywhere. We don’t yet have demographic data about how many midwives are LGBTQI2S+ or how they are distributed throughout the country. There is also a tab that illustrates the percent of “Black Births” by state, but not the race of the midwives, and other racial categories are not mapped for percent of births of midwives. 

For information about the LGBTQI2S+ population State-by-State, the Williams Institute has done extensive demographic research and has a map which can be accessed at: https://williamsinstitute.law.ucla.edu/visualization/lgbt-stats/?topic=LGBT#density These are complex demographics to calculate, not to mention complex categories to define. Notably, the Williams Institute categorizes people demographically as “LGBT” whereas The Equality Maps uses “LGBTQ.”

Based on the Williams Institute data, 4.5% of the adult population in the United States is LGBT, 29% are raising children, and 25% have income of less than $24k per year (another myth the Williams Institute has tackled is that LGBT people are more affluent than their heterosexual counterparts: they are not). This data project includes the “LGBT People Rankings” where the percentage of LGBT people who are raising children are ranked for twenty states. The highest, is Idaho where 44% of LGBT people are raising children, followed by Utah, Oklahoma, Arkansas, Delaware and Mississippi. 

This information can be combined with the Equality Maps created by the Movement Advancement Project (MAP) which can be accessed at: http://www.lgbtmap.org/equality-maps 

Together, these three maps provide a view of how midwifery integration lines up with the policy climate for LGBTQ people and families. 

The Equality Maps indicate “policy tallies” of all the states. State scores are ranked in five gradations from “High” to “Negative.” The policy tally combines the Sexual Orientation Policy Tally and the Gender Identity Policy Tally. You can also look at the map based on the Sexual Orientation Policy Tally alone or on the Gender Identity Tally alone. Overall, 46% of LGBTQ people are living in states with “High” or “Medium” scores, and 45% of LGBTQ people are living in states with “Negative” or “Low” scores. 

The policy tallies come from MAP's tracking of dozens of LGBTQ-related laws. Those laws fall into seven categories: Relationship and Parental Recognition, Nondiscrimination, Religious Exemptions, LGBTQ Youth, Health Care, Criminal Justice, Identity Documents (it’s possible to look more deeply into each of these types of laws in their methodology information). The states aren’t ranked from highest to lowest like they are for the midwifery integration scores, but you can look at the data in a table instead of as a map. 

In the state profile you can see both tallies, plus the percentage of the state’s population that is LGBTQ and the percent of LGBTQ people in the state raising children. Population numbers are based on estimates created by demographic researchers so there is some interpretation involved (which explains why the percentages in this map vary a bit from the percentages in the Williams Institute maps referenced below). The numbers are not broken down by gender identity, sex,or race, and it’s not easy to determine how many of those raising children gave birth to those children.

By way of example, Washington is in the “medium” category overall (and “high” for Gender Identity) and 5.2% of the adult population is LGBTQ, with 29% of those folks raising children. North Carolina is in the “low” category overall (and “negative” for Gender Identity), and 4% of the adult population there is LGBTQ, with 26% of them raising children. Missouri is also in the “low” category overall, and have a lower percent of the adult population who identify as LGBTQ (3.8%), but even more of them are raising children (30%). 

One of the most interesting discoveries from the demographic data about LGBTQ people is how many LGBTQ families are in rural areas and areas with negative laws. For example, Kansas, which is near the bottom in terms of midwifery integration, and is also near the bottom in terms of equality tallies, nonetheless is a place where 40% of the LGBTQ population is raising children. This is something to consider for LGBTQ midwives or midwives especially interested in serving the LGBTQ population.

We analyzed midwifery integration scores, midwifery density, Equality Tallies, and LGBT population (both the percent of the overall population that is LGBT and the percent of the LGBT population raising children for the top 20 States). 

Three states stood out for their high scores (top twenty) in all five categories: Delaware, New Hampshire, and New Mexico. That means in these three states, midwifery integration is among the highest in the country, overall equality tallies are among the highest, the percentage of the population that is LGBT is among the highest, and the percentage of LGBT people raising children is among the highest.  

Five states were in the top twenty in four out of five of these categories: Hawaii, New York, Oregon, Vermont and Washington. In these states there are several things going for midwives and LGBT folks. Hawaii had a lower midwifery integration score that set it apart. The other four had a slightly smaller percentage of the LGBT population raising kids.

Seven states had three out of five scores in the top twenty: California, Colorado, Maine, Massachusetts, Rhode Island, Utah and Wisconsin. Utah and Wisconsin had lower Equality Tallies which set them apart in this group, but sizable proportions of the LGBT population raising kids and decent midwifery density. In contrast, Maine and Massachusetts didn’t make the top twenty in terms of percent of the LGBT population raising kids - but their rates were still high. Colorado wasn’t quite as strong in midwifery integration but had more midwifery density, while California lacked midwifery density but had a decent integration score (again, keeping in mind that 61 was a high score out of 100, so all top 20 states have room for improvement).

Seven states are worth looking twice at despite some problematic scores because they present an opportunity in some way: Arkansas, Idaho, Indiana, Maryland, Minnesota, Nebraska, Nevada. For example, Arkansas has a -.5 Equality Score, but 36% of the LGBT population there is raising kids, and the midwifery integration score is in the middle of the pack. Idaho, mentioned above, has the highest percent of the LGBT population raising kids, a high integration score, and a low equality tally, but one that is not “negative” (the lowest level).  

Six states have the unfortunate distinction of having high proportions of LGBT families, combined with “negative” Equality Tallies, and fair-to-good midwifery integration: Mississippi, Oklahoma, South Carolina, South Dakota, Tennessee, and Texas. These states might have something to offer midwives, but should also be scrutinized carefully for a realistic view of how dangerous the climate could be for LGBT people. 

As far as we know midwifery integration and LGBTQI2S+ equality have never been analyzed together, and there is room for more analysis across the board. From analyzing midwifery density by more detailed demographics (like the race and LGBTQI2S+ identity of midwives), to analyzing how the children who are being raised by LGBTQI2S+ folks were born, and the demographics of those families by race, and gender. Not to mention surveying the experiences of LGBTQI2S+ families during the perinatal period (check out Birth Includes Us).

Despite the relatively small numbers in the population of midwives and the populations of LGBTQI2S+ people, this is important work from an equity perspective. As efforts to increase the midwifery workforce continue, so do efforts to ensure that workforce is diverse and capable of meeting the needs of the community including people of color, LGBTQI2S+ people, and LGBTQI2S+ people of color.

This was originally written in February of 2020. Some data may have changed.