In an interview with Ms., the authors of The Perfect Birth Myth explain how Project 2026’s pronatalist agenda ignores the policies that would actually improve maternal health and birth outcomes. People protest Project 2025 in front of the Heritage Foundation in Washington, D.C., on March 16, 2025. (Bonnie Cash / AFP via Getty Images)

When the Heritage Foundation released “Saving American by Saving the Family” (known colloquially as Project 2026) earlier this year, the authors lamented the “precipitous drop in fertility” in the United States and a “record low” birth rate of 1.59 lifetime deliveries per woman. Blame for the decline, they wrote, rested with feminism, the sexual revolution, abortion availability, no-fault divorce and a declining number of heterosexual marriages.

Other factors—including systemic barriers to accessing pre-and postnatal care, Medicaid cuts, racism, sexism and the failure of medical professionals to take the concerns of pregnant women seriously—were not mentioned.

The Perfect Birth Myth: Pushing Back Against a Broken Industry by Avital Norman Nathman with Deborah Wage challenges the Heritage Foundation’s assessment and examines gaps in maternity care—sometimes called maternity care deserts—throughout the country.

It also lambastes the U.S. as a world leader in maternal mortality, noting that a 2022 report from the Commonwealth Fund found an appalling 24 deaths per 100,000 live births overall, but 55 deaths per 100,000 births for Black women—“more than three times the rate in other highly-developed countries.” 

For Nathman and Wage, utilization of doulas and midwives, group prenatal care, paid parental leave after delivery, and regular follow-up visits to evaluate a new parent’s physical and emotional well-being, would go a long way in improving birth and post-partum outcomes. The Perfect Birth Myth not only advocates for these policies but offers ways that public health and reproductive justice activists (and other concerned people) can promote better, more equitable and respectful healthcare.

Nathman and Wage spoke to Ms. reporter Eleanor J. Bader ahead of the book’s Sept. 17 release.

---

Eleanor J. Bader: You surveyed nearly 3,000 people before writing the book. Who were these people? How did you find them? And when was the survey conducted?

Avital Norman Nathman: The survey went on for years! We started before the pandemic, when I posted the survey on my Facebook page. Then Deb [Wage] posted it on her page, and it spread from there. There was also a lot of word-of-mouth outreach from folks, and somehow the survey, using a Google Form, went viral.

This was shocking to us because it was not a short questionnaire. It was long and detailed, but people clearly wanted to share their stories. We got responses from a really diverse group of people from around the country.

… It was startling to me that an out-of-pocket delivery at home with a midwife could be cheaper than giving birth at an in-network provider, and that cost was a real motivator for some people when choosing where and how to give birth.

Avital Norman Nathman

Deborah Wage: We sent a different survey to providers because we wanted to hear from OB-GYN physicians,  doulas and midwives, and they, too, were eager to respond.

Bader: Did any of the survey results surprise you?

Wage: I was an assistant professor in the Department of Obstetrics at Vanderbilt University for 10 years when I practiced as a family nurse practitioner and certified nurse midwife, but am now retired. My research has always focused on how we can reimagine the way care is delivered to improve patient outcomes.

We knew there were a lot of myths surrounding birth—among them, that ‘natural’ is always best and that a birth plan assures a healthy, easy delivery—but, for me, these myths were more prevalent than I expected.

The financial constraints people told us about were validating. I knew financial issues led to discontinuity of care, but it was unbelievably validating to hear this expressed directly.

Nathman: I knew that a small number of people opt for home births, but it was startling to me that an out-of-pocket delivery at home with a midwife could be cheaper than giving birth at an in-network provider, and that cost was a real motivator for some people when choosing where and how to give birth.

Bader: The maternal mortality statistics, especially for Black women, are horrifying. Why has this not gotten consistent attention from mainstream media?

Nathman: When someone like Beyoncé, Serena Williams, or another prominent woman of color has a traumatic birth or a complicated pregnancy, they have large platforms so the media pays attention for a few days. Then the coverage dies down.

I also think there is some complacency, and people, including reporters, believe these outcomes are just how it is. As birth has become more medicalized, they’ve just shrugged these traumas off. We don’t hear much public discussion outside of the birth community about ways to improve birth outcomes, which is why we included them in The Perfect Birth Myth.

Wage: We don’t live in a country with a philosophy that supports public health. Our society tends to be compartmentalized, and we tend to focus on individual actions. ‘If you can afford it, or have medical coverage that will pay for a midwife or doula, you can hire them.’ It’s presented as a personal choice. This leads to a profound inequality of care, but many people believe the myth that the U.S. is the best country in the world for everything, including healthcare.

… Utilization of doulas and midwives, group prenatal care, paid parental leave after delivery, and regular follow-up visits to evaluate a new parent’s physical and emotional well-being, would go a long way in improving birth and post-partum outcomes.

Bader: Have groups like the American College of Obstetricians and Gynecologists  (ACOG) pushed for policies and changes to reduce maternal mortality rates?

Wage: Yes. During the past five to 10 years, ACOG and other groups (like the American College of Nurse Midwives) have been much more solidified in their efforts. There are actually a lot of organizations pushing back, but there are constant hurdles they are trying to overcome: opposition from the insurance industry, Medicaid cuts, hospital and delivery room closures.

Bader: How has the second Trump administration impacted care delivery and outcomes?

Nathman: Several months into the second Trump administration, the Centers for Disease Control suspended data collection through PRAM, The Pregnancy Risk Assessment Monitoring System, that used to identify groups of women and girls who were at risk of pregnancy-related health problems. PRAM had existed since 1988 and monitored maternal mortality in the states.

Stopping this was like ending the tracking of COVID-19 cases. There are no deaths if data is not collected and there is therefore no need to intervene.

Wage: Since January 2024, states that were already bad in terms of birth outcomes have gotten worse and states with the strictest abortion bans have also shown worse maternal health outcomes. Poverty has also skyrocketed. 

Protesters rally outside the Heritage Foundation building on June 9, 2025, in Washington, D.C., against Project 2025, developed by Heritage. (Andrew Harnik / Getty Images)

Bader: Have any federal lawmakers tried to reverse any of this?

Nathman: The Black Maternal Health Caucus has been trying to pass the Momnibus Act since 2020 and it has been reintroduced every cycle. The caucus is chaired by Rep. Alma Adams (D-N.C.)  and Rep. Lauren Underwood (D-Ill.). The act would expand WIC for postpartum care and invest in maternal health to reduce mortality rates, but it has yet to pass. It’s mind-boggling since promoting healthy births should be a nonpartisan issue.

We know what we’re doing wrong in the U.S. In essence, not having universal health care is a roadblock for better pregnancy care. But in addition, in the U.S., OB-GYN doctors outnumber midwives three to one.

In New Zealand, one of the safest countries in the world to give birth, there are 46 midwives for 11 OB-GYNs. We know that if we had more midwives, domestic birth outcomes would improve but we are instead fixated on a medicalized model.

Wage: Midwives aren’t magic but they offer a model of care that improves birth outcomes. Red states tend to have more restrictions on midwives than blue states, and they tend to put regulations on birth centers that essentially require them to operate like hospitals. There are always lots of hoops to jump through when opening a birthing center, but local and state governments in red states make it nearly impossible for them to open and offer care.

When I was at Vanderbilt—I left in 2018—I got a large grant from the state of Tennessee to create mechanisms that would improve birth outcomes. We considered many things to propose for grant funding that were known to improve outcomes and chose to focus on group prenatal care. We found that group prenatal care was very successful and had a huge impact on outcomes.

But group care was just one potential solution. We know eight to 12 visits with an OB-GYN provider does not work well for every person, but the common denominator of positive outcomes is giving pregnant people support and autonomy. We listened to them and offered group care to everyone we cared for in traditional care, all demographics, from high-income professionals, to people with preexisting health conditions, to people from under-resourced areas.

Unfortunately, when the funding went away the provision of care reverted to the traditional medical care model.

Bader: The insurance industry and medical establishment have put up roadblocks to equitable care. How can they be pressured to make changes?

Nathman: You’d think they’d want better birth outcomes, but they do not seem concerned. Maternity wards are costly and are considered loss leaders, which is why they are the first to be cut or closed when a hospital faces a budgetary shortfall. It’s why maternity care voids exist.

Wage: The insurance industry and their lobbyists are against expanding the scope of practice to include anything that cuts into their dollars.

The number one factor for a bad birth outcome is being Black. It’s shocking …

Wage

Bader: What role has the feminist movement played in promoting better birth outcomes?

Nathman: Reproductive justice work always includes mention of birth, but it usually amounts to an afterthought. Of course, I understand that access to abortion and birth control need to top the priority list, but many people still make the choice to get pregnant and give birth. At the same time, a lot of people are doing birth equity work at the grassroots level.

They are rarely on magazine covers and aren’t the people speaking at galas, but the Southern Birth Justice Network in Florida, for one, has a mobile unit to help people who’d otherwise have to take three buses to get to a prenatal care provider. There are a lot of other examples of this type of effort and we describe many of them in the book. They are run by people who see pregnancy and maternal health as part-and-parcel of reproductive justice work.    

Bader: The right wing has been extremely vocal about the so-called “birth dearth.” Have any conservative groups advocated for the kinds of policy and care shifts you suggest?

Nathman: No. Part of this is their fantasy that the woman who gives birth will stay at home with the baby and her husband will go out to work. That’s why they don’t support paid medical and family leave after a baby is born. They don’t see the need for other family supports, either.

Wage: ‘Family values’ are such a load of shit. The number one factor for a bad birth outcome is being Black. It’s shocking, but people tend to blame the individual: “Oh, she smoked. She was overweight. She was poor.” None of this matters. She can be a 13-year-old teen or a lawyer. She can be middle-aged. It doesn’t matter. All Black women feel this, know this.

Nathman: The innate racism starts at birth. After years of poor medical treatment, actually after generations of poor medical treatment, there is a cumulative impact on the Black body. Even if you control for education and income, all Black women experience racism, which leads to inferior medical care. 

Bader: Has the midwifery or doula community addressed this? 

Wage: In addition to racial inequality, there are other issues dividing the doula and midwifery communities and there is some pushback against them being in labor and delivery rooms. Some people argue that if they’re incorporated into mainstream medical care, they’ll become part of the system and be beholden to the hospital.

A lot of midwives and doulas embrace this idea, believing that if you work in a hospital you’re selling your soul. I don’t agree. I’ve seen certified nurse midwives involved in the care of pregnant people with medical complications, and I’ve seen them let laboring patients dance around their room. I want to see doulas and midwives become part of the standard practice of care.

Melina Laverde, left, performs cranial sacral therapy on Sanaai Lynae, 2 weeks old, during a postpartum checkup on Destyni McClain in Houston, on July 25, 2025. (Ashleigh Lucas / Houston Chronicle via Getty Images)

Bader: Medical students are the future of that care. Are they being taught about racial disparities? Are they learning to respect doulas and midwives? Are they addressing the disparities that lead to high maternal mortality for Black patients?

Wage: I taught a lot of medical students and supervised residents who were trained well. But if a doctor ends up working for an institution that does not employ certified nurse midwives or doulas, they may have to deal with traditional systems of care.

We stopped doing routine episiotomies at Vanderbilt, but later I heard from a former resident that they were told that they would have to do them, so we’re still facing a lot of obstacles.

The Perfect Birth Myth: Pushing Back Against a Broken Industry, by Avital Norman Nathman with Deborah Wage, will be released Sept. 17, 2026. It is now available for preorder.

This interview has been edited for clarity.

*

A note from Ms. editors: We want to hear from you for The Majority, a new campaign collecting stories about how reproductive freedom has enabled readers to build the lives they want and need. Poll after poll shows a majority of Americans support reproductive healthcare access. Yet public debate overlooks the lives shaped by abortion access, contraception, IVF, miscarriage care, maternal healthcare or comprehensive sex education—countless women who chose to pursue an education, have children, not have children, protect their health and chart their own future. Add your voice and complete the sentence: “Access to reproductive choices gave me the freedom to….” Together, these stories will help show not only why reproductive freedom remains a majority value, but also what it makes possible. 

Look to these trusted groups if you or a loved one needs to know more about reliable abortion care:

• A one-stop-shop for abortion seekers: I Need An A
• Other websites to explore all your options for abortion care: Plan C Pills, Abortion Finder
• Safe websites to buy abortion medication: Aid Access, Massachusetts Medication Abortion Access Project, Hey Jane
• If you need help affording abortion care, tell your telemedicine provider or contact an abortion fund near you.
• To protect your digital privacy when planning your abortion, click here.
• For free legal help as a patient or doctor, call If/When/How’s Repro Helpline—844-868-2812—or contact Pregnancy Justice.
• For medical advice, contact the Miscarriage & Abortion Hotline: 833-246-2632.
• If you need to know the abortion law in your state, look to the Center for Reproductive Rights. or Guttmacher Institute.