Fierce Debate Over Midwifery Licensure

Pamela Merritt

Currently, Missouri midwives must have a nursing degree and work under a doctor's supervision -- otherwise, they are committing a felony. A Senate bill under consideration would expand women's birthing options -- but the Missouri State Medical Association is fighting back.

A friend of mine is expecting her first child and when I last spoke to her she was in the midst of putting her birthing plan together. I have to confess that I was a little alarmed, since this is the same friend who ended up with three binders full of information and a battle plan complete with multiple exit strategies when she got married. But as our conversation progressed I realized that, with so many options to consider and some serious decisions to make, a birthing plan is a pretty good idea.

One of the birthing options many people consider is whether to use a midwife and, as Barbara Kantrowitz and Pat Wingret pointed out in their Newsweek piece The Delivery Debate, making that decision can be very confusing. Beyond the basic medical and personal considerations, some states are debating legislation that may impact access to midwifery care. Here in Missouri, State Senate has been debating Senate Bill 1021, which "changes the laws regarding midwives and the practice of midwifery." The debate over whether to regulate midwifery, how that regulation would take place, and which body would oversee that regulation has been fierce.

Currently, Missouri midwives must have a nursing degree and work under a doctor's supervision — otherwise, they are committing a felony by overseeing the care of a pregnant patient. But Senate Bill 1021 would

"create a 'Board of Direct-Entry Midwives' [midwives who begin their education in midwifery directly rather than after completing a nursing program] within the Division of Professional Registration. The board shall have the power to issue licenses and to suspend, revoke or deny the license of a direct-entry midwife. The board shall develop practice guidelines regarding the practice of midwifery established by the National Association of Certified Professional Midwives, including the development of collaborative relationships with other healthcare practitioners who can provide care outside the scope of midwifery when necessary."

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Steff Hedenkamp of The Big Push for Midwives Campaign, a group pushing for the regulation and licensure of Certified Professional Midwives in all 50 states and the District of Columbia, was in Jefferson City, Missouri, during the recent Senate debate. Hedenkamp said that she talked to a lot of Senators and Representatives who support Senate Bill 1021 because they like the compromises made and the way it will address concerns about liability, education, certification and licensing.The bill passed out of committee five to one which is proof, according to Hedenkamp, that there is political will to pass it if it were brought to the floor for an up-or-down vote.

Protecting and defending the ability of certified midwives to provide legal and safe healthcare is an essential part of the reproductive justice movement, as Amie Newman explored in her article A New Life For Midwifery Care. Amie argues that "restricting access to a full-range of health care providers, especially those known to improve health outcomes for maternal and newborn health, is not healthy for women and babies."

Yet those opposed to legislation like Missouri's Senate Bill 1021 claim that protecting maternal and newborn health is also their motivation. As reported by Michelle Munz of the St. Louis Post-Dispatch, the Missouri State Medical Association is lobbying for greater doctor supervision of midwives, stating a concern for public safety.

The group wants midwives to have written collaborative-practice agreements with a physician that will justify regulation by the Board of Healing Arts. An amendment proposed by Senator Graham, D-Columbia, would place the regulation of midwives under that physician registration board. But 24 other states license midwives and the majority of them do so without physician involvement with direct-entry midwives, instead licensing and certifying them through midwifery boards or committees.

Advocates for Senate Bill 1021 point out that regulating midwifery through the Board of Healing Arts would set a dangerous precedent of having one profession regulate another. Hedenkamp feels that the Graham amendment guts the bill and that the physician-based board would simply not issue licenses, effectively regulating midwives out of existence.

As things currently stand, Senate Bill 1021 may not go to the floor for an up-or-down vote. But midwifery advocates pledge to continue the fight. Hedenkamp says that "we will continue to work hard, continue to tell our stories, continue to shine light on and give voice to what Missouri families want: legal access to licensed Certified Professional Midwives in the state, and now."

Culture & Conversation Maternity and Birthing

On ‘Commonsense Childbirth’: A Q&A With Midwife Jennie Joseph

Elizabeth Dawes Gay

Joseph founded a nonprofit, Commonsense Childbirth, in 1998 to inspire change in maternity care to better serve people of color. As a licensed midwife, Joseph seeks to transform how care is provided in a clinical setting.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

Jennie Joseph’s philosophy is simple: Treat patients like the people they are. The British native has found this goes a long way when it comes to her midwifery practice and the health of Black mothers and babies.

In the United States, Black women are disproportionately affected by poor maternal and infant health outcomes. Black women are more likely to experience maternal and infant death, pregnancy-related illness, premature birth, low birth weight, and stillbirth. Beyond the data, personal accounts of Black women’s birthing experiences detail discrimination, mistreatment, and violation of basic human rights. Media like the new film, The American Dream, share the maternity experiences of Black women in their own voices.

A new generation of activists, advocates, and concerned medical professionals have mobilized across the country to improve Black maternal and infant health, including through the birth justice and reproductive justice movements.

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Joseph founded a nonprofit, Commonsense Childbirth, in 1998 to inspire change in maternity care to better serve people of color. As a licensed midwife, Joseph seeks to transform how care is provided in a clinical setting.

At her clinics, which are located in central Florida, a welcoming smile and a conversation mark the start of each patient visit. Having a dialogue with patients about their unique needs, desires, and circumstances is a practice Joseph said has contributed to her patients having “chunky,” healthy, full-term babies. Dialogue and care that centers the patient costs nothing, Joseph told Rewire in an interview earlier this summer.

Joseph also offers training to midwives, doulas, community health workers, and other professionals in culturally competent, patient-centered care through her Commonsense Childbirth School of Midwifery, which launched in 2009. And in 2015, Joseph launched the National Perinatal Task Force, a network of perinatal health-care and service providers who are committed to working in underserved communities in order to transform maternal health outcomes in the United States.

Rewire spoke with Joseph about her tireless work to improve maternal and perinatal health in the Black community.

Rewire: What motivates and drives you each day?

Jennie Joseph: I moved to the United States in 1989 [from the United Kingdom], and each year it becomes more and more apparent that to address the issues I care deeply about, I have to put action behind all the talk.

I’m particularly concerned about maternal and infant morbidity and mortality that plague communities of color and specifically African Americans. Most people don’t know that three to four times as many Black women die during pregnancy and childbirth in the United States than their white counterparts.

When I arrived in the United States, I had to start a home birth practice to be able to practice at all, and it was during that time that I realized very few people of color were accessing care that way. I learned about the disparities in maternal health around the same time, and I felt compelled to do something about it.

My motivation is based on the fact that what we do [at my clinic] works so well it’s almost unconscionable not to continue doing it. I feel driven and personally responsible because I’ve figured out that there are some very simple things that anyone can do to make an impact. It’s such a win-win. Everybody wins: patients, staff, communities, health-care agencies.

There are only a few of us attacking this aggressively, with few resources and without support. I’ve experienced so much frustration, anger, and resignation about the situation because I feel like this is not something that people in the field don’t know about. I know there have been some efforts, but with little results. There are simple and cost-effective things that can be done. Even small interventions can make such a tremendous a difference, and I don’t understand why we can’t have more support and more interest in moving the needle in a more effective way.

I give up sometimes. I get so frustrated. Emotions vie for time and energy, but those very same emotions force me to keep going. I feel a constant drive to be in action and to be practical in achieving and getting results.

Rewire: In your opinion, what are some barriers to progress on maternal health and how can they be overcome?

JJ: The solutions that have been generated are the same, year in and year out, but are not really solutions. [Health-care professionals and the industry] keep pushing money into a broken system, without recognizing where there are gaps and barriers, and we keep doing the same thing.

One solution that has not worked is the approach of hiring practitioners without a thought to whether the practitioner is really a match for the community that they are looking to serve. Additionally, there is the fact that the practitioner alone is not going to be able make much difference. There has to be a concerted effort to have the entire health-care team be willing to support the work. If the front desk and access points are not in tune with why we need to address this issue in a specific way, what happens typically is that people do not necessarily feel welcomed or supported or respected.

The world’s best practitioner could be sitting down the hall, but never actually see the patient because the patient leaves before they get assistance or before they even get to make an appointment. People get tired of being looked down upon, shamed, ignored, or perhaps not treated well. And people know which hospitals and practitioners provide competent care and which practices are culturally safe.

I would like to convince people to try something different, for real. One of those things is an open-door triage at all OB-GYN facilities, similar to an emergency room, so that all patients seeking maternity care are seen for a first visit no matter what.

Another thing would be for practitioners to provide patient-centered care for all patients regardless of their ability to pay.  You don’t have to have cultural competency training, you just have to listen and believe what the patients are telling you—period.

Practitioners also have a role in dismantling the institutionalized racism that is causing such harm. You don’t have to speak a specific language to be kind. You just have to think a little bit and put yourself in that person’s shoes. You have to understand she might be in fear for her baby’s health or her own health. You can smile. You can touch respectfully. You can make eye contact. You can find a real translator. You can do things if you choose to. Or you can stay in place in a system you know is broken, doing business as usual, and continue to feel bad doing the work you once loved.

Rewire: You emphasize patient-centered care. Why aren’t other providers doing the same, and how can they be convinced to provide this type of care?

JJ: I think that is the crux of the matter: the convincing part. One, it’s a shame that I have to go around convincing anyone about the benefits of patient-centered care. And two, the typical response from medical staff is “Yeah, but the cost. It’s expensive. The bureaucracy, the system …” There is no disagreement that this should be the gold standard of care but providers say their setup doesn’t allow for it or that it really wouldn’t work. Keep in mind that patient-centered care also means equitable care—the kind of care we all want for ourselves and our families.

One of the things we do at my practice (and that providers have the most resistance to) is that we see everyone for that initial visit. We’ve created a triage entry point to medical care but also to social support, financial triage, actual emotional support, and recognition and understanding for the patient that yes, you have a problem, but we are here to work with you to solve it.

All of those things get to happen because we offer the first visit, regardless of their ability to pay. In the absence of that opportunity, the barrier to quality care itself is so detrimental: It’s literally a matter of life and death.

Rewire: How do you cover the cost of the first visit if someone cannot pay?

JJ: If we have a grant, we use those funds to help us pay our overhead. If we don’t, we wait until we have the women on Medicaid and try to do back-billing on those visits. If the patient doesn’t have Medicaid, we use the funds we earn from delivering babies of mothers who do have insurance and can pay the full price.

Rewire: You’ve talked about ensuring that expecting mothers have accessible, patient-centered maternity care. How exactly are you working to achieve that?

JJ: I want to empower community-based perinatal health workers (such as nurse practitioners) who are interested in providing care to communities in need, and encourage them to become entrepreneurial. As long as people have the credentials or license to provide prenatal, post-partum, and women’s health care and are interested in independent practice, then my vision is that they build a private practice for themselves. Based on the concept that to get real change in maternal health outcomes in the United States, women need access to specific kinds of health care—not just any old health care, but the kind that is humane, patient-centered, woman-centered, family-centered, and culturally-safe, and where providers believe that the patients matter. That kind of care will transform outcomes instantly.

I coined the phrase “Easy Access Clinics” to describe retail women’s health clinics like a CVS MinuteClinic that serve as a first entry point to care in a community, rather than in a big health-care system. At the Orlando Easy Access Clinic, women receive their first appointment regardless of their ability to pay. People find out about us via word of mouth; they know what we do before they get here.

We are at the point where even the local government agencies send patients to us. They know that even while someone’s Medicaid application is in pending status, we will still see them and start their care, as well as help them access their Medicaid benefits as part of our commitment to their overall well-being.

Others are already replicating this model across the country and we are doing research as we go along. We have created a system that becomes sustainable because of the trust and loyalty of the patients and their willingness to support us in supporting them.

Photo Credit: Filmmaker Paolo Patruno

Joseph speaking with a family at her central Florida clinic. (Credit: Filmmaker Paolo Patruno)

RewireWhat are your thoughts on the decision in Florida not to expand Medicaid at this time?

JJ: I consider health care a human right. That’s what I know. That’s how I was trained. That’s what I lived all the years I was in Europe. And to be here and see this wanton disregard for health and humanity breaks my heart.

Not expanding Medicaid has such deep repercussions on patients and providers. We hold on by a very thin thread. We can’t get our claims paid. We have all kinds of hoops and confusion. There is a lack of interest and accountability from insurance payers, and we are struggling so badly. I also have a Change.org petition right now to ask for Medicaid coverage for pregnant women.

Health care is a human right: It can’t be anything else.

Rewire: You launched the National Perinatal Task Force in 2015. What do you hope to accomplish through that effort?

JJ: The main goal of the National Perinatal Task Force is to connect perinatal service providers, lift each other up, and establish community recognition of sites committed to a certain standard of care.

The facilities of task force members are identified as Perinatal Safe Spots. A Perinatal Safe Spot could be an educational or social site, a moms’ group, a breastfeeding circle, a local doula practice, or a community center. It could be anywhere, but it has got to be in a community with what I call a “materno-toxic” area—an area where you know without any doubt that mothers are in jeopardy. It is an area where social determinants of health are affecting mom’s and baby’s chances of being strong and whole and hearty. Therein, we need to put a safe spot right in the heart of that materno-toxic area so she has a better chance for survival.

The task force is a group of maternity service providers and concerned community members willing to be a safe spot for that area. Members also recognize each other across the nation; we support each other and learn from each others’ best practices.

People who are working in their communities to improve maternal and infant health come forward all the time as they are feeling alone, quietly doing the best they can for their community, with little or nothing. Don’t be discouraged. You can get a lot done with pure willpower and determination.

RewireDo you have funding to run the National Perinatal Task Force?

JJ: Not yet. We have got the task force up and running as best we can under my nonprofit Commonsense Childbirth. I have not asked for funding or donations because I wanted to see if I could get the task force off the ground first.

There are 30 Perinatal Safe Spots across the United States that are listed on the website currently. The current goal is to house and support the supporters, recognize those people working on the ground, and share information with the public. The next step will be to strengthen the task force and bring funding for stability and growth.

RewireYou’re featured in the new film The American Dream. How did that happen and what are you planning to do next?

JJ: The Italian filmmaker Paolo Patruno got on a plane on his own dime and brought his cameras to Florida. We were planning to talk about Black midwifery. Once we started filming, women were sharing so authentically that we said this is about women’s voices being heard. I would love to tease that dialogue forward and I am planning to go to four or five cities where I can show the film and host a town hall, gathering to capture what the community has to say about maternal health. I want to hear their voices. So far, the film has been screened publicly in Oakland and Kansas City, and the full documentary is already available on YouTube.

RewireThe Black Mamas Matter Toolkit was published this past June by the Center for Reproductive Rights to support human-rights based policy advocacy on maternal health. What about the toolkit or other resources do you find helpful for thinking about solutions to poor maternal health in the Black community?

JJ: The toolkit is the most succinct and comprehensive thing I’ve seen since I’ve been doing this work. It felt like, “At last!”

One of the most exciting things for me is that the toolkit seems to have covered every angle of this problem. It tells the truth about what’s happening for Black women and actually all women everywhere as far as maternity care is concerned.

There is a need for us to recognize how the system has taken agency and power away from women and placed it in the hands of large health systems where institutionalized racism is causing much harm. The toolkit, for the first time in my opinion, really addresses all of these ills and posits some very clear thoughts and solutions around them. I think it is going to go a long way to begin the change we need to see in maternal and child health in the United States.

RewireWhat do you count as one of your success stories?

JJ: One of my earlier patients was a single mom who had a lot going on and became pregnant by accident. She was very connected to us when she came to clinic. She became so empowered and wanted a home birth. But she was anemic at the end of her pregnancy and we recommended a hospital birth. She was empowered through the birth, breastfed her baby, and started a journey toward nursing. She is now about to get her master’s degree in nursing, and she wants to come back to work with me. She’s determined to come back and serve and give back. She’s not the only one. It happens over and over again.

This interview has been edited for length and clarity.

News Law and Policy

GOP Pushes LGBTQ Discrimination on Pulse Shooting Anniversary

Christine Grimaldi

A business or other organization drawing on taxpayer money and acting on those views, for instance, could deny child care, health care, and retirement benefits to an employee with a same-sex spouse without penalty from the federal government.

On the one-month anniversary of the massacre at the Pulse nightclub in Orlando, Florida, congressional Republicans pushed legislation that would shield individuals and groups that receive federal funds from penalties for discriminating against LGBTQ people.

A U.S. House of Representatives committee Tuesday debated the First Amendment Defense Act (FADA). Republicans have proposed multiple official and unofficial versions of FADA. All of them share a common purpose: Protect recipients of federal dollars that act on their “religious belief or moral conviction” against same-sex marriage or sex outside of marriage. Conservative groups such as the Heritage Foundation have praised FADA for building on broader Religious Freedom Restoration Act (RFRA) and other so-called religious liberty bills. (The legal website Justia breaks down the similarities and differences between RFRA and FADA.)

A business or other organization drawing on taxpayer money and acting on those views, for instance, could deny child care, health care, and retirement benefits to an employee with a same-sex spouse without penalty from the federal government, Democratic lawmakers opposing the bill said at the House Oversight and Government Reform Committee hearing. Employers could even refuse to provide time off under the Family and Medical Leave Act to care for an ill same-sex spouse.

That possibility troubled Jim Obergefell, the plaintiff in the landmark U.S. Supreme Court ruling on marriage equality. “This is not the kind of dignity and respect that the Supreme Court spoke so eloquently of in the decision granting the freedom to marry nationwide last June,” Obergefell told lawmakers.

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If enacted into law, FADA would also empower those with religious objections to be able to turn away LGBTQ people seeking services such as housing or medical care, experts testified before the committee.

Rep. Elijah Cummings (D-MD), the committee’s ranking member, fellow Democrats, and 80 civil rights and other groups petitioned Republicans to reschedule the FADA hearing, to no avail. More than 3,000 faith and clergy last year leaders voiced their opposition to FADA, he said.

“To say that this hearing is ill-timed is the understatement of the year,” Cummings said as he opened the hearing. That evening, House Democrats and the Congressional LGBT Equality Caucus gathered on the capitol steps for a vigil honoring the 49 victims of the Pulse shooting.

Rep. Raúl Labrador (R-IN) introduced the House’s bill (H.R. 2802), and Sen. Mike Lee (R-UT), the identical Senate counterpart (S. 1598). FADA has little to no chance of becoming law this year given President Barack Obama’s increasingly outspoken support for the LGBTQ community, indicating that he would veto any such legislation that somehow managed to advance in the House and Senate. A Mississippi judge recently blocked a similar state law from taking effect.

House Democratic aides provided Rewire with a revised FADA draft that they said Labrador has been circulating since last Friday that goes even further.

Lawmakers and witnesses at the hearing discussed the revised draft, which they said would apply to all businesses—both for-profit and nonprofit. This draft permits discrimination against same-sex and opposite-sex couples except by federal employees acting in the scope of their employment and for-profit federal contractors acting in the scope of a government contract, they added.

David Stacy, the government affairs director for the Human Rights Campaign, the prominent LGBTQ civil rights group, described these exemptions, and others for hospital visitations and medical decisions, as concessions that don’t mask FADA’s underlying discrimination.

“That all being said, the bill has really significant problems that remain,” he said in an interview.

Columbia School of Law professor Katherine Franke underscored that FADA would go beyond permitting discrimination against LGBTQ individuals and include unmarried parents and heterosexual couples.

“A broad reading of this bill would create a safe harbor from penalties associated with an enormous range of behavior that is otherwise illegal or prohibited by federal law and regulation,” Franke said in her testimony before the committee.

Under FADA, she said, the federal government could not deny Title X funding to a health-care clinic that provides family planning services only to patients that can furnish a marriage license. Nor could the government deny a Violence Against Women Act grant to a domestic violence shelter that required residents to pledge their opposition to marriage equality or extramarital relations, she added.

Schools that accept federal funds could fire teachers suspected of having premarital sex, the Huffington Post reported. NARAL Pro-Choice America highlighted the “legislation that lets your boss fire you for having premarital sex (yes, really)” in a scathing memo sent to reporters.

“Are you a single mother whose landlord doesn’t believe in sex outside of marriage? Under this law, your landlord could refuse to house you,” the memo said. “Do you work at a company where your boss doesn’t believe in premarital sex? Under this law, if your boss found out about your private life, they could fire you.”