Standing behind a table stacked with fliers, Lakita Matthews is trying to educate women about their birth options. It isn’t easy. At this sparsely-attended health fair in the District’s Deanwood neighborhood, most of the people who wander by are more interested in discussing more immediate issues like primary care and health insurance.

A woman with cherry-colored streaks in her hair and two little girls in tow stops by the table and Matthews, the patient services manager for DC’s Family Health and Birth Center, begins her pitch. “We’re the only freestanding birth center in DC; we do natural births and can also do hospital births,” she says. But the woman has stopped listening. “Natural birth?” she asks incredulously. “I don’t do natural,” she says, shaking her head and moving on. 

 The exchange—and the event itself—illustrates Matthews’ quandary. Staffed by midwives who strive to deliver babies without medical intervention, the Family Health and Birth Center is dedicated to improving birth outcomes among low-income women in the area, most of whom are African American. But over the past three years, FHBC, located just off of Benning Road in Northeast Washington, has seen a surge in wealthier clients who use private insurance. Meanwhile, the number of poor women covered by Medicaid has dropped.

The reason? It’s a complicated mix of factors that include shifting demographics, culture, and the bare-bones pragmatism demanded by poverty. But the upshot is simple: a premium standard of care designed for and readily available to low-income women is going under-utilized by them, while those with money are recognizing its value and flocking to it.

The increased interest in natural childbirth among professionals isn’t unique to DC. It’s a nationwide phenomenon among educated women that was spurred in part by talk show host Ricki Lake’s 2008 documentary, “The Business of Being Born,” which follows a midwife in her work.

Indeed, women who elect to have midwives deliver their babies--whether at home, in a hospital, or in a birth center--consistently report better experiences and healthier babies. FHBC, for example, boasts negative birth outcomes that are roughly half the national averages. According to the CDC, the national C-section rate is 32.8 percent, the pre-term birth rate is 11.7, and the rate for low birth weight babies is 8.1 percent. Meanwhile at FHBC, the rates are 17 percent for C-sections, 6 percent for pre-term births, and 3 percent for babies with low birth weight.

So it’s not surprising that FHBC, like all of the area’s midwifery practices and birth centers, has become popular among women who are proactive and assertive about their health. In the three years since the center first opened its doors to privately-insured women, they’ve grown to comprise about half of its patients.

 Which isn’t necessarily a bad thing. FHBC’s midwives are nowhere near capacity yet, so it’s not like women of means are elbowing their poorer counterparts aside. “We want to provide to who comes,” says Kelly McShane, executive director of Community of Hope, the nonprofit organization that runs FHBC.

 But the center, established in 2000, has always made serving poor women its main priority. FHBC (which also offers primary health care) is a rare model, but a critical one. Across all races, African American women, particularly those of low income, consistently have the worst birth outcomes, and are arguably in much greater need of midwifery care than affluent white women. And yet FHBC’s number of Medicaid patients has dropped by approximately half over the past three years.

 In part, that’s the result of DC’s changing demographics. Once set squarely in a large poor community, the center drew clients who noticed the building while walking by or got its name from girlfriends who lived nearby. But these days, FHBC is only a few blocks from the uber-fashionable H Street NE corridor and isn’t far from an expanding Capitol Hill. There are simply fewer poor people around; 2010 Census data shows that every census tract around the center has become wealthier and whiter.

FHBC and Community of Hope staff know they need to increase their outreach efforts, but it’s not easy. “We worry that if we market the birth center, we’ll get a ton of privately insured women,” says McShane. That’s where Matthews, the patient services manager, comes in: hired in August, she and a colleague plan to build partnerships with groups like social workers and churches. 

They could take a tip from Washington Hospital Center, which runs a midwifery initiative catering to a largely low-income population. According to Loral Patchen, who directs the program, staff do robust outreach, regularly showing up at public schools and community events. But its location in a hospital also gives the program a constant flow of potential clients—and instant respectability.

After all, birth—like other big milestones, such as marriage and death—is a loaded and deeply personal subject, one that’s heavily influenced by culture and family.  

“We still get folks whose moms or best friends say a birth center is for poor people, for the uninsured,” explains Karen Pelote, FHBC’s clinical manager. Natural home births were black women’s only option well into the 20th century; who wouldn’t pick the prestige and professionalism of a doctor in a hospital now, given the choice?

In fact, FHBC’s clients are welcome to give birth in a hospital using the center’s midwives. But the organization’s staff would like to see their birthing rooms—where women can relax in a supportive, bedroom-like setting—get more use. Currently, only about a fifth of their poor clients elect to have their babies there. 

Carmen Montgomery, one of FHBC’s low-income patients, used the center’s midwives for all six of her children’s births, but every one was born in the hospital. “I wanted to use the birth center [rooms], but I was scared,” she explains. “It’s just scary not to be in the hospital, where normal people go.”

That’s a typical response, says Claudia Booker, an African American midwife in the region. Because the natural birth trend hasn’t yet trickled down to low-income women, changing their attitudes “is going to take time, and people they trust,” she says. FHBC staff know this; they’ve discussed building support by inviting extended family members to prenatal group meetings.

They also know that dealing with poor women from any background has built-in challenges. For instance, women who use the birthing rooms have to leave about four hours after delivering their babies; the organization doesn’t have the staff to keep them overnight. That can be a serious disincentive for some, says Pelote. “Maybe they need this time for themselves; maybe they don’t want to rush home because so many people are at their house.”

 For low-income mothers-to-be, that’s just one issue among many. In essence, it’s a question of resources: choosing an alternative birth is likely to require more energy, preparation, and time, say the midwives who work with low-income populations . All of those might be in short supply among women with many other worries, including the stresses of pregnancy.

But as a result, deciding on a natural birth can be especially powerful for women who don’t often get to be architects of their own experiences. “A birth experience that’s really what you want, where you get the support you need—that’s a life-altering experience,” says Patchen, the Washington Hospital Center midwife. “And I think there are particular benefits for low-income women.”

Amanda Abrams is a freelance writer living in Washington, D.C.