Midwife Connection: How Is Real Midwifery Practiced?

Leslie Ludka

Whenever I think about midwifery as a career, I remember Sister Angela Murdaugh’s words: “Midwifery is a calling. If you do not believe that you were called, you should get out of midwifery.” But, how do we know if we were called?

October 4-10 is National Midwifery Week!
Each year during National Midwifery Week, midwives across the US raise
awareness of the midwifery profession and the services provided to
women. Rewire will be publishing a series of posts this week
from the American College of Nurse-Midwives blog, Midwife Connection,
to recognize this week – and the care midwives, Certified
Nurse-Midwives and Certified Professional Midwives, provide. Need a
quick Midwife 101? Read more.    

Editor’s Note from ACNM blog, Midwife Connection: In honor of National Midwifery Week, we asked Leslie Ludka to write an encore post based on her article “Are You Practicing Real Midwifery?” (click on the article for a sneak peak at Quickening, ACNM’s members-only newsletter!). Leslie is a regular columnist for Quickening and is Director of Midwifery at Cambridge Hospital and Birth Center in Cambridge, MA.

Whenever I think about midwifery as a career, I remember Sister Angela Murdaugh’s words: “Midwifery is a calling. If you do not believe that you were called, you should get out of midwifery.”

But,
how do we know if we were called? Does it have to manifest in a
specific type of job in a specific type of setting? Is it only a
calling if we can’t wait to get up every morning and rush to work? Does
being financially successful make it a calling?

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I’m not sure
about you, but for most of us, midwifery is neither easy nor lucrative.
In fact, there are times when midwifery is the hardest job in the
world—just ask any midwife to tell you the story of that case that
haunts her memories. We all have one. In fact, there are times when our
work is so difficult that no amount of money would attract most
rational people.

So, why would anyone choose midwifery? I
believe that Sister Angela has it right. Midwifery is not a choice; it
is a calling. We do not choose midwifery; midwifery chooses us. When I
went to midwifery school, I never asked if there would be a job for me
when I finished. I didn’t wonder how much money I would make. I know it
sounds crazy, but the truth is, it didn’t matter. Midwifery is my
calling.

A calling fulfills your personal mission in life. It
feeds your spirit by using your unique gifts and abilities to satisfy
your deep inner purpose. Following your calling means staying on the
path of that which you feel most passionate about, even when it is
difficult. A calling is about truly loving what you do.

As we celebrate National Midwifery Week, let’s honor the diversity of this amazing calling of midwifery by sharing with each other and our supporters. Tell
us, how has midwifery called you: clinical practice, education,
administration, or something else? How do you live your calling?

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.

Culture & Conversation Human Rights

How One Couple Is Putting Bathroom Safety on the Map

Ryan Thomas

Like the Negro Motorist Green Book, the Safe Bathrooms map is not so much a novelty but a vital resource to protect the safety of its users at a time when history is repeating itself in a way that is marginalizing an already vulnerable population.

This piece was published in collaboration with Generation Progress.

North Carolina Gov. Pat McCrory (R) seems to think it’s a governor’s duty to classify which men and women are the “real” ones and which aren’t. Because of this, he has put the lives of all of North Carolina’s trans residents at risk by signing HB 2 into law.

Last week state legislators proposed changes to HB 2, but those changes do nothing to mitigate an unabashed blastoma of transphobia that is now lawfully spreading at a vicious pace.

In response to HB 2, droves of businesses and musicians have boycotted the state in hopes of stopping this unmitigated discrimination toward trans people from moving any further.

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People have banded together to show their support for the trans community, and businesses across the state and country have declared themselves safe havens for trans-identifying individuals by submitting to the Safe Bathrooms map.

The map’s creators—River William Luck, a trans community activist, and his partner (and as of recently, fiancée), web design specialist Emily Rae Waggoner—both live in Boston, but the fight to protect trans rights affects them on a deeply personal level: They’re both from North Carolina.

When HB 2 was signed into law, Luck says, “I was on guard, because I’ve been told I’m in the wrong bathroom my entire life as a masculine-presenting female for more than 30 years.”

Now his home state has become one big ”Do Not Enter” sign for him and his friends still there. Luck’s reaction, however, was not one of helplessness. His instinct, which he learned to follow after years of experiencing and bearing witness to bigotry, was to bind the community and help strengthen it through tangible acts of love and support.

One Reddit commenter likened the map to the Negro Motorist Green Book of the 1930s to 1960s, which was published to help Black travelers in the United States find safe passage in times when racial persecution was legal. Like the Negro Motorist Green Book, the bathrooms’ map is not so much a novelty but a vital resource to protect the safety of its users at a time when history is repeating itself in a way that is marginalizing an already vulnerable population.

Before the Safe Bathrooms map, Luck started mailing hundreds of buttons from the #IllGoWithYou campaign to friends and family back home. The #IllGoWithYou campaign was developed as a means for allies to offer solidarity and protection to transgender and non-binary individuals. By wearing a button, participants pledge to stand up and speak up during instances of harassment and physical endangerment.

“This is my way of paying it forward,” Luck says. “What I’ve done is buy a shit ton of buttons and if someone wants one, I send them one. If they can’t afford it, I send them one. If they want to know more about it, I write them a note and ask people to pick up more.”

His reasoning is simple: “I would have given anything to have seen one of these when I was in North Carolina.”

Luck’s meaningful gestures extends to the clothes he wears, as he frequently can be found sporting a t-shirt that says “No Hate in Our State” or a tank top with the words “Proud Transman” printed in bold. River models several lines of what he refers to as “activism wear,” as a product ambassador a variety of labels including a Greensboro, North Carolina-based company called Deconstructing Gender, and another called Proud Animals.

It’s actually the former that planted the seed for the Safe Bathrooms map, as Luck and Waggoner were inspired by the photos of gender-neutral bathrooms posted on the company’s Instagram account. While the two were talking to Deconstructing Gender’s founder and CEO Avery Dickerson, who was transitioning at the time, Waggoner said, “Wouldn’t it be nice if there was a map of safe bathrooms where trans people could go without hassle?”

And so with Waggoner’s web design expertise and Luck’s social media skills, the Safe Bathrooms map came to life as a child of both necessity and wishful thinking. As they built it, the people came in droves: businesses, affected community members, and media alike.

With over 200 businesses included to date, the two have put together a functioning survival guide for trans residents and travelers who also possess bladders.

Waggoner shared one email with Rewire that she received from a man who owns an architecture firm in Maine, who requested to have his business be included on the map:

I, therefore this business, stand for equality, acceptance, and kindness to all. As a gay man, and one living with HIV for 30 years now, I know too well that indifference to discrimination, condoned cruelty, and legalized oppression are terminal illnesses. These behaviors killed the dreams, and injured the very souls of our young, and further darkened the roads the rest of us continue to travel. It must stop.

To be included on the Safe Bathrooms map, businesses need simply fill out this form and verify their trans-friendliness with a photo of a gender-neutral bathroom placard or other clear form of expression. Upon approval, businesses are represented on the map as a roll of toilet paper. For those lacking, the Safe Bathrooms website goes one step further and shows businesses where they can obtain gender-neutral bathroom signs for their private spaces.

Waggoner and Luck know personally how useful such a map can be. Waggoner says she’s had to stake out bathrooms to make sure the coast is clear, like a Secret Service member. One time, she says, “We were in a restaurant waiting to use the bathroom. We could feel the tension in the air and feel the stares. And it became very uncomfortable because people at the bar were openly just watching which bathroom River was going to go into. And we feared for his safety and our safety.”

Luck continues, “We ended up having to leave and go to a friend’s house so I could use the bathroom and detoured the whole evening plans so I could pee safe.”

Clearly the problem won’t end once HB 2 and other anti-trans laws like it are repealed. The attitudes that brought these policies into being still exist and must be dealt with. But, as Luck attests, there is a definite support system of love and acceptance in North Carolina. He found it in Greensboro as a music teacher at New Garden Friends School, a Quaker school. “They were so open and embraced diversity that I could be an out lesbian,” says Luck.

Greensboro has very distinct pockets of support, which is where a lot of the safe bathrooms appear on the map. But even in places less supportive deeper south, Waggoner notes there are still good friends to be found: “It’s been cool to see some of the small-business owners in some of the more rural towns popping up. Like in Salisbury, North Carolina. It’s really brave of them to do that—to be the first in their town to speak up and say something, and be the first on the map.”

The outpouring of support may be having an effect: University of North Carolina President Margaret Spellings recently gave a statement saying that she would not enforce HB 2 or change any of the school’s current provisions. Spellings did originally plan to enforce HB 2. It wasn’t until U.S. Attorney General Loretta Lynch declared the state in violation of civil rights and threatened to cut up to $4.8 billion in federal funding to the school that Spellings changed her position (and McCrory sued the federal government).

Before Spellings changed her decision, students from various on-campus alliance groups held loud protests outside of buildings in which she was attending meetings, in efforts to sway her judgment. Students at schools across the state affected by the law are making their opposition known.

On a K-12 level, there are organizational efforts through nonprofit Gay-Straight Alliance groups such as Time Out Youth, which offers resources and aid to LGBTQ minors living in inclusive North Carolina and South Carolina school districts. Its website lists student rights, including the rights to gender expression, confidentiality, and respective pronoun usage, as well the right to attend school functions and report on instances of bullying (which state public schools are required by law to deal with).

Luck has spent most of his life traveling against the grain of society’s intolerance–from a misunderstood kid living with his grandparents, to a determined and proud trans man working hard to end the ritual persecution of his fellow person.

Growing up in North Carolina in a conservative Baptist household, Luck remembers being called a “tomboy” and being told “not to act like a boy” as young as 3 years old. Luck attended and was eventually kicked out of a Christian high school for identifying as a “lesbian” (this was before he identified as trans). Luck says he’s been working steadily since he was 13, when his first job was at a Chick-fil-A.

In college, Luck had a psychology professor who taught that homosexuality was a disorder.

“I remember sitting in the class waiting for someone to say something, because I didn’t want to say anything,” Luck says.

After going to the head of the psych department, and then the head of the school, Luck managed to get the homophobic lesson pulled from the syllabus.

“That was a time in my life where I realized if I didn’t say something, no one would. And so I had to. That’s when my activism really started,” Luck says.

Coming to Boston for grad school, Luck found his new home to be much less critical of his outward gender appearance, and found true love in his partner. Luck says Waggoner accepted and supported his transition every step of the way—from coming out (a second time) as transgender, to life-affirming surgeries and ongoing treatments, to his sweeping romantic proposal involving a trip to New York City, a rare Harry Potter book, and a cleverly inserted engagement ring.

Luck and Waggoner hope to expand upon all the ground they’ve covered in North Carolina and take their Safe Bathrooms map to national and international levels.

Luck says he wants to ultimately see the whole state of North Carolina become “a giant roll of toilet paper.”

“We’d [also] love for it to grow to be an international thing, especially given all the anti-LGBT sentiments in other countries. Because we’re everywhere. And everybody needs to have that access,” he says.

The two do have an app in the works to accompany their Safe Bathrooms map, which they hope to give a Yelp-like interface to allow community members to find safe bathrooms on the go, and review and share their own individual bathroom experiences.

All of this work points to a very simple goal: to make it so trans people don’t have to endure daily humiliation exercises to find a toilet that comes with no strings attached.

“The bottom line is … I’m a human being who happens to be trans. But before I would label myself trans, I would say I’m an activist, an actor, a student, an artist, a musician, a good partner, a good relative … All these other qualities that define me that have so much more weight,” says Luck.

To show support for the trans community and be included on the Safe Bathrooms map, visit SafeBathrooms.club.