Three Pillars of Maternal Health

Judith F. Helzner

Critical maternal health interventions can be funded without overhauling health systems. What's missing is the political will.

A woman lies bleeding in the emergency room of the University of
Ibadan College Hospital in Nigeria. Though her baby was delivered safely, she’s suffering
from postpartum hemorrhage, an easily treatable condition that nonetheless kills
approximately 160,000 women in the Global South annually—about 30 percent of all
maternal deaths. In the past, this woman would likely have died in as little as two hours.

But today, a low-cost, wet-suit-like outfit can save her. Made of neoprene and Velcro,
the AntiShock Garment or LifeWrap, enfolded around the new
mother’s lower body, can decrease bleeding and keep blood in her vital organs. It will
help stabilize her, allowing time to transport her to an appropriate facility, for a surgeon
to be called or for enough blood to be collected for her transfusion.

This is one of several low-tech, low-cost interventions that could
dramatically reduce maternal mortality in the Global South, where each
year more than half a million women die from preventable
pregnancy related causes—one every minute.

In 2000, the United Nations
identified reduction of maternal mortality as one of eight Millennium
Development Goals (MDGs) — global priorities designed to help end poverty, decrease maternal and infant mortality, ensure gender equality, combat HIV/AIDS to name a few. Yet
this issue is struggling for visibility and funding, lost in the
competition for billions of dollars allocated for global health.
Consequently, while such innovations as the AntiShock Garment offer
women real hope, the challenge is how to make them widely available.

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Another helpful postpartum intervention
is the inexpensive, uterine contracting
drug misoprostol, which
has been shown by research in India to
prevent up to half of all postpartum
hemorrhaging if administered within a
few minutes after delivery. If a woman
does start bleeding, the AntiShock
Garment then stabilizes her. Or, if a
woman suffers from eclampsia due to
complications from hypertension—
which can lead to convulsions and accounts
for about 12 percent of all
maternal deaths—she can best be
helped by the drug magnesium sulfate.
But that remedy is rarely used because
of problems with availability, staff
training or health-facility readiness.

In the past, experts in the maternal
health field have disagreed on priority
actions. But within the past year a consensus
has emerged on the three pillars
necessary to support a sustained
drop in pregnancy-related deaths:

  • Comprehensive reproductive health
    care must include contraception to
    avoid unwanted births and prenatal
    visits to monitor pregnant women.
  • Skilled attendance at birth must
    mean ensuring that danger signs are
    identified early for at-home births,
    or births in modest primary healthcare
    centers, and that timely actions
    are taken to prevent complications
    or to bring women to more sophisticated
    facilities.
  • It is a critical investment to increase
    capacity for emergency obstetric
    care, including operating rooms for
    C-section deliveries and stocked
    blood banks for transfusions.

 

These interventions can be funded and
introduced without overhauling health
systems. Other steps needed to improve
maternal health aren’t so clearcut.
But based on the billions spent
each year on such global health issues
as HIV/AIDS—not to mention expenditures
for issues other than health—
it’s obvious that resources exist.

What’s missing is the political will.
For the global community to meet
commitments made in the Millennium
Development Goals, attention
and resources need to be redirected,
and greater concern put forth by
health experts, government officials
and ordinary citizens. As Thoraya
Obaid, director of the U.N. Population
Fund, noted, “It would cost the
world less than two and a half days’
worth of military spending to save
the lives of 6 million mothers, newborns
and children every year.”

The full text of this
article appears in the Summer issue of Ms. magazine, available on
newsstands or by joining the Ms. community at www.msmagazine.com.

Roundups Politics

Campaign Week in Review: Clinton Criticizes Trump’s Child-Care Proposal in Economic Speech

Ally Boguhn

Hillary Clinton may be wooing Republicans alienated by Trump, but she's also laying out economic policies that could shore up her progressive base. Meanwhile, Trump's comments about "Second Amendment people" stopping Hillary Clinton judicial appointments were roundly condemned.

Hillary Clinton may be courting Republicans, but that didn’t stop her from embracing progressive economic policies and criticizing her opponent’s child-care plan this week, and Donald Trump suggested there could be a way for “Second Amendment people” to deal with his rival’s judicial appointments should she be elected.

Clinton Blasts Trump’s Child-Care Proposal, Embraces Progressive Policies in Economic Speech

Democratic nominee Hillary Clinton took aim at Republican nominee Donald Trump’s recently announced proposal to make the average cost of child care fully deductible during her own economic address Thursday in Michigan.

“We know that women are now the sole or primary breadwinner in a growing number of families. We know more Americans are cobbling together part-time work, or striking out on their own. So we have to make it easier to be good workers, good parents, and good caregivers, all at the same time,” Clinton said before pivoting to address her opponent’s plan. “That’s why I’ve set out a bold vision to make quality, affordable child care available to all Americans and limit costs to 10 percent of family income.”

“Previously, [Trump] dismissed concerns about child care,” Clinton told the crowd. “He said it was, quote, ‘not an expensive thing’ because you just need some blocks and some swings.”

“He would give wealthy families 30 or 40 cents on the dollar for their nannies, and little or nothing for millions of hard-working families trying to afford child care so they can get to work and keep the job,” she continued.

Trump’s child-care proposal has been criticized by economic and family policy experts who say his proposed deductions for the “average” cost of child care would do little to help low- and middle-wage earners and would instead advantage the wealthy. Though the details of his plan are slim, the Republican nominee’s campaign has claimed it would also allow “parents to exclude child care expenses from half of their payroll taxes.” Experts, however, told CNN doing so would be difficult to administer.

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Clinton provided a different way to cut family child-care costs: “I think instead we should expand the Child Tax Credit to provide real relief to tens of millions of working families struggling with the cost of raising children,” Clinton said in Michigan on Thursday. “The same families [Donald Trump’s] plan ignores.”

Clinton also voiced her support for several progressive policy positions in her speech, despite a recent push to feature notable Republicans who now support her in her campaign.

“In her first major economic address since her campaign began actively courting the Republicans turned off by Donald Trump, Clinton made no major pivot to the ideological center,” noted NBC News in a Thursday report on the speech. “Instead, Clinton reiterated several of the policy positions she adopted during her primary fight against Bernie Sanders, even while making a direct appeal to Independent voters and Republicans.”

Those positions included raising the minimum wage, opposing the Trans-Pacific Partnership trade deal, advocating for equal pay and paid family leave, and supporting a public health insurance option.

“Today’s speech shows that getting some Republicans to say Donald Trump is unfit to be president is not mutually exclusive with Clinton running on bold progressives ideas like debt-free college, expanding Social Security benefits and Wall Street reform,” said Adam Green, the co-founder of the Progressive Change Campaign Committee, in a statement to NBC.

Donald Trump: Could “Second Amendment People” Stop Clinton Supreme Court Picks?

Donald Trump suggested that those who support gun ownership rights may be able to stop Democratic nominee Hillary Clinton from appointing judges to the Supreme Court should she be elected.

“Hillary wants to abolish, essentially abolish the Second Amendment,” Trump told a crowd of supporters during a Tuesday rally in Wilmington, North Carolina. “By the way … if she gets to pick her judges, nothing you can do, folks. Although, the Second Amendment people—maybe there is. I don’t know.” 

Trump campaign spokesperson Jason Miller later criticized the “dishonest media” for reporting on Trump’s comments and glossed over any criticism of the candidate in a statement posted to the campaign’s website Tuesday. “It’s called the power of unification―Second Amendment people have amazing spirit and are tremendously unified, which gives them great political power,” said Miller. “And this year, they will be voting in record numbers, and it won’t be for Hillary Clinton, it will be for Donald Trump.”

“This is simple—what Trump is saying is dangerous,” said Robby Mook, Clinton’s campaign manager, in a statement responding to the Republican nominee’s suggestion. “A person seeking to be the President of the United States should not suggest violence in any way.”

Gun safety advocates and liberal groups swiftly denounced Trump’s comments as violent and inappropriate for a presidential candidate.

“This is just the latest example of Trump inciting violence at his rallies—and one that belies his fundamental misunderstanding of the Second Amendment, which should be an affront to the vast majority of responsible gun owners in America,” Erika Soto Lamb, chief communications officer of Everytown for Gun Safety, said in a Tuesday statement. “He’s unfit to be president.”

Michael Keegan, president of People for the American Way, also said in a Tuesday press release, “There has been no shortage of inexcusable rhetoric from Trump, but suggesting gun violence is truly abhorrent. There is no place in our public discourse for this kind of statement, especially from someone seeking the nation’s highest office.”

Trump’s comments engaged in something called “stochastic terrorism,” according to David Cohen, an associate professor at the Drexel University Thomas R. Kline School of Law, in a Tuesday article for Rolling Stone.

“Stochastic terrorism, as described by a blogger who summarized the concept several years back, means using language and other forms of communication ‘to incite random actors to carry out violent or terrorist acts that are statistically predictable but individually unpredictable,’” said Cohen. “Stated differently: Trump puts out the dog whistle knowing that some dog will hear it, even though he doesn’t know which dog.”

“Those of us who work against anti-abortion violence unfortunately know all about this,” Cohen continued, pointing to an article from Valerie Tarico in which she describes a similar pattern of violent rhetoric leading up to the murders that took place at a Colorado Springs Planned Parenthood.

What Else We’re Reading

Though Trump has previously claimed he offered on-site child-care services for his employees, there is no record of such a program, the Associated Press reports.

History News Network attempted to track down how many historians support Trump. They only found five (besides Newt Gingrich).

In an article questioning whether Trump will energize the Latino voting bloc, Sergio Bustos and Nicholas Riccardi reported for the Associated Press: “Many Hispanic families have an immense personal stake in what happens on Election Day, but despite population numbers that should mean political power, Hispanics often can’t vote, aren’t registered to vote, or simply choose to sit out.”

A pair of physicians made the case for why Gov. Mike Pence “is radically anti-public health,” citing the Republican vice presidential candidate’s “policies on tobacco, women’s health and LGBTQ rights” in a blog for the Huffington Post.

Ivanka Trump has tried to act as a champion for woman-friendly workplace policies, but “the company that designs her clothing line, including the $157 sheath she wore during her [Republican National Convention] speech, does not offer workers a single day of paid maternity leave,” reported the Washington Post.

The chair of the American Nazi Party claimed a Trump presidency would be “a real opportunity” for white nationalists.

NPR analyzed how Clinton and Trump might take on the issue of campus sexual assault.

Rewire’s own editor in chief, Jodi Jacobson, explained in a Thursday commentary how Trump’s comments are just the latest example of Republicans’ use of violent rhetoric and intimidation in order to gain power.

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.

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