A Birth Space Revolution?

Dr. Katharine Hikel

Midwives have always placed a great deal of importance on the physical space for childbirth, the personal relationships of those who attend the birth, and the metaphysics of the birth spaces to which women will consciously or unconsciously respond. A new book details, for providers, just how critical these elements are to an optimal birth experience - and how most birthing women currently don't have these options.

This book review is reposted with permission from The Science & Sensibility Blog from Lamaze International. 

The next vital revolution in maternity care may well be the overhaul and redesign of the birthplace.
In “Birth Territory and Midwifery Guardianship,” writers describe the
relationship of the birth setting to the emotional-physiological state
of laboring women.  In this regard, ‘Birth Territory’ encompasses not
only physical space, but also personal relationships, power structures,
and access to knowledge.

Maternity care as we know it has evolved along divergent roads: the
midwifery, expectant-management ‘natural’ approach; and the obstetric,
interventive, ‘actively-managed’  model.  Midwifery care is a
woman-centered approach; it relies on relationships which support
women’s natural abilities to give birth. The obstetric model, designed
by and for doctors, operates on  principles of academic exclusiveness, described by Louis Menand:

It is a self-governing and largely closed community of
practitioners who have an almost absolute power to determine the
standards for entry, promotion, and dismissal in their fields. The
discipline relies on the principle of disinterestedness, according to
which the production of new knowledge is regulated by measuring it
against existing scholarship through a process of peer review, rather
than by the extent to which it meets the needs of interests external to
the field…

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[T]he most important function of the system is not the production of
knowledge. It is the reproduction of the system. To put it another way,
the most important function of the system, both for purposes of its
continued survival and for purposes of controlling the market for its
products, is the production of the producers

Academic obstetrics is impervious to knowledge and input from other
disciplines; it exists in a closed, parallel world; it exists not for
the purpose of taking care of women, but for the purpose of taking care
of itself. The chief concern of any obstetrical unit is the viability
of the department, of the program; if outcomes figure into that, well
and good; but women’s actual experiences and opinions, because they are
not part of the published literature, are of no concern.  Small wonder,
then, that so little thought has been given to the environment of
hospital birth, other than for the convenience of hospital
practitioners.

Meanwhile, midwives have continually concerned themselves with what the authors of Birth Territory and Midwifery Guardianship
call ‘the elements in the geography, architecture, and metaphysics of
birth spaces to which women will consciously and unconsciously respond.’

In their book, the writers – midwives, and an architect of birth
spaces – asked women what they wanted in their birthing places.
Responses included:

  • A pleasant place to walk
  • Sufficient pillows, floor mats, bean bags
  • Availability of snacks and drinks
  • En suite toilet, shower, bath; a birth pool
  • Comfortable accommodations for companions and families
  • A homey, non-clinical environment
  • Control over temperature
  • Control over brightness of light
  • Privacy; not being overheard by others
  • Not being watched
  • Control over who comes into the room

 

The majority of birthing women surveyed did not have these options.
The authors argue that lack of a woman-centered birthing environment,
and little control over that environment, are reasons for high rates of
obstetric intervention. Labor and birth are whole-being experiences;
the autonomic nervous system will shut the whole process down if the
woman perceives stress, threat, or danger.  In typical hospital
settings, with shift changes, strangers walking in and out, bright
lights, confinement to bed and monitor, and restricted oral intake, it
is no wonder that the process doesn’t go as smoothly as it could.
“Failure to progress” – the diagnostic reason given for 50% or more
cesareans – is largely an environmental issue.

 

Birth territory is also defined by relationships; yet medical
obstetrics has constantly worked to sequester birthing women away from
all sources of comfort, including non-medical practitioners; only in
the 1960s were fathers and partners invited into hospital delivery
rooms; and only lately, with the advent of doula practices, has
one-to-one attendance – the cornerstone of midwifery – become
recognized as a significant predictor of good outcome.  But few
hospital practices are relationship-centered. Prenatal visits are
fifteen or twenty minutes long, mainly focused on weight gain and lab
work. There’s usually a team of doctors and midwives; the person who’s
available at the time of one’s birth is not a matter of preference, but
of the practice’s call schedule.

Obstetrics is statistics-based, not relationship-based;
obstetricians know that the average due date is 40 weeks from the last
menstrual period; they know that if a woman is laboring (in a hospital)
with waters broken for over 12 hours, her chance of infection
skyrockets; they know that the Friedman labor curve shows that the
average progression of dilation is one centimeter per hour; they know
that the average pushing phase is under two hours. They are under
pressure to make everyone fit those statistical norms, and they have
the tools to make it so; and that’s what they do.

The best birth territory requires the best attendants. Fahy and her
coauthors argue that birth is a reflection of relationships – with
oneself, and with others; that relationships depend on love, and
spiritual development (words you will never see in any obstetrical
textbook).  In developing the best birth attendants, they see
open-heartedness as a requirement for good practice; they describe the
characteristics of a good practitioner in Buddhist terms of ‘right
relationship’: empathy; ethical behavior; self-awareness; capacity for
love. In a chapter called “Reclaiming the sacred in birth,” they
describe the conditions for nurturing ideal midwives: ‘to know and
nurture themselves within their own families and communities,’ and
emphasizes working on personal development, as well as clinical skills,
with a supervisor or professional partner. The training environment of
midwives should encourage the development of nurturing and intimate,
though professional, relationships with her clients; it is that
relationship that forms a necessary part of optimal birth territory.

The territory of obstetrics residents is largely devoid of
patient-relationship considerations; it is rather consumed with
concerns about on-call hours, clinical rotations, numbers of
procedures, and one’s place in the departmental hierarchy. The
knowledge itself is based in pathology – ‘problem-oriented’ – a
diagnostic/treatment approach that assumes there’s trouble, and goes
about finding it. This works well in the rest of medicine, which is
really about disease; but colors the teaching approach to the normal,
healthy event of childbirth.  The knowledge that’s important – taught
and practiced – is all within the limits of academic obstetrics, which
ignores, if not devalues, ‘nonscientific’ knowledge. The ‘permitted’
knowledge supports what the authors call the ‘metanarrative’ of
academic medicine: the postmodern myth that the safest and best place
to give birth is under obstetric management. Any knowledge that
counters that myth is disputed or ignored.

The history of obstetrics is also viewed differently from within the
specialty than without. The obstetricians’ view, reproduced in most
obstetrical textbooks, is the development of one intervention after
another, all by men – from forceps to vacuum extractions. The authors
present a larger-scale view:

Medicine in the late 19th and early 20th centuries was
composed almost entirely of men who shared the same power base as other
dominant males: they were white, well-educated and from economically
richer families. It was these males who owned or managed every
institution of society: the army, the church, the law, the newspapers,
the government, etc. These privileges, combined with an informal
brotherhood of dominant men, created a powerful base for the success of
the medical campaign to subordinate midwifery.

The authors describe the territory of hospital birth as disputed
ground, where the biological requirements of birthing women are at odds
with the design of institutions.  They provide ample evidence about how
the dominance of obstetricians’ needs over women’s welfare has
contaminated the culture of birth. In a wonderful section on oxytocin –
the hormone of love, bonding, social interaction, birth, and lactation
– they describe the effects of this natural hormone:

[T]he higher the level of Oxytocin, the more calm and
social the mother; thereby stress is reduced; levels of the stress
hormone cortisol drop; pain threshold is increased…  body temperature
is regulated… and heart rate and blood pressure are lowered… Women’s
response to stess may not be the automatic ‘fight or flight’ response
seen in men, but is more likely to be the ‘calm and connection’ system
integrated by Oxytocin.

These oxytocin-mediated events are most necessary during labor and
birth; they are best enabled if the birth territory includes
oxytocin-positive relationships.  Oxytocin is thought to be the source
of women’s power to endure labor and birth; and its pathways are the
most likely to be deranged by the institutional birth environment – the
lack of oxytocin-facilitating relationships of trust and love, as well
as the routine administration of oxytocin-blocking drugs such as
epidurals and Pitocin – a form of artificial oxytocin that has never
been proven safe in long-term outcome studies. Blocking oxytocin,
whether through fear, disturbance, or Pitocin, leads to disrupted or
painfully difficult labors.  These authors suggest that disruption of
normal oxytocin pathways, and supplanting them with intrapartum Pitocin
exposure, may also result in serious mental health problems on the
love-and-relationship axis: schizophrenia, autism, drug dependency,
suicidal tendencies, and antisocial criminal disorders. It’s not just
the mother who’s affected by the birth territory.

But what is the best birth environment?  In a chapter called
“Mindbodyspririt architecture: Creating birth space,” architect Bianca
Lepori describes her designs for hospital-based birth rooms that are
meant to enhance, not counteract, women’s abilities to give birth. She
created suites of rooms with “Space and freedom to move; to be able to
move to the dance of labor; to respond to the inner movements of the
baby; to walk, kneel, stretch, lie down, lean, squat, stand, and be
still.” The rooms have “Soft and yielding surfaces; or firm and
supportive surfaces; different textures; the right temperature; soft
curves; darkness or dim light.” A birthing woman can be ‘immersed in
water, flowing or still; respected, safe, protected, and loved.” 
Access to the suite is through an antechamber; the bed is farthest away
from the lockable door, and not visible from it, so that privacy is
respected.

Lepori’s birth architecture reproduces the comforts of home. There
is access to the outdoors, and private walking places. There are birth
stools, exercise balls, bean bags, hooks for hammocks or ropes for
stretching. Tubs and beds are large and accessible from both sides.
There are accommodations for families. There are comfortable chairs for
nursing. Medical equipment – supplies, oxygen – is tucked behind a
screen or put in a closet. A refrigerator and light cooking equipment
is available. This ‘birth territory’ certainly outshines the typical
hospital OB floor; though it begs the question: Why not just stay home?

The answer, of course, is that, for those four to ten percent of
births that truly need intervention, the OR is right there. It’s better
not to have to transport a woman whose labor has turned complicated; it
makes sense – for many – to have all the birth territory under one roof.

This birthing-suite design indeed takes into account the
all-encompassing, body-mind-spirit event of childbirth. It honors
laboring, birthing women and families; it respects the process. It
worked well for a designated maternity hospital in New Zealand
– a facility already designed for childbearing. But most US hospitals
are multi-use facilities; and though obstetrics is among the best
money-makers for hospitals, childbirth is the only event that occurs
there that is not related to illness or trauma.

The real question is, why not remove birth completely from the pathology-centered hospital model?
Why not redesign birth territory to maximize best outcomes, minimize
intervention, and replace the present medicalized view of birth as a
disaster waiting to happen with the more normative,
expectant-management, midwifery view? Move the whole shebang, from the
waiting room to the surgical suite, out of the hospital and back into
the community where it belongs.

Why not indeed. The major obstacle to any redesign of the territory
of birth is resistance from the field of obstetrics. The American
Congress of Obstetricians and Gynecologists (which recently changed its
name from the American College of Obstetricians and Gynecologists,
reflecting a major shift in interest from academics to politics) has a
23-member lobbying arm, “OB-GYNS for Women’s Health PAC”, which
describes itself on its web site:

Ob-Gyns for Women’s Health and Ob-Gyn PAC help elect
individuals to the U.S. House of Representatives and Senate who support
us on our most important issues. Individuals who understand the
importance of our work, who care about the future of our specialty, who
listen to our concerns, and who vote our way. In only a few short
years, Ob-Gyn PAC has helped elect ob-gyns and other physicians to the
U.S. Congress, and has become one of the largest and most influential
physician PACs in America.

Only five of the 23 members
are women; all ten of its board of directors are men. Current issues
occupying the group are “Stopping Medicare payment cuts, ensuring
performance measures work for our specialty, preserving in-office
ultrasounds” (though there are still no long-term studies on the
effects of ultrasound on the developing fetus, or on women, for that
matter); and “winning medical liability reform,” which means limiting
liability for malpractice.
Meanwhile,  the Medicaid Birth Center Reimbursement Act – Senate Bill
#S.1423 (House Bill HR 2358) – is not on the list of bills that ACOG
supports, even though this expansion of birth territory would probably
better outcomes, and certainly cost less than the hospital OB model.

The only bad thing about “Birth Territory and Midwifery Guardianship” is that obstetricians will not read it.

Analysis Economic Justice

New Pennsylvania Bill Is Just One Step Toward Helping Survivors of Economic Abuse

Annamarya Scaccia

The legislation would allow victims of domestic violence, sexual assault, and stalking to terminate their lease early or request locks be changed if they have "a reasonable fear" that they will continue to be harmed while living in their unit.

Domestic violence survivors often face a number of barriers that prevent them from leaving abusive situations. But a new bill awaiting action in the Pennsylvania legislature would let survivors in the state break their rental lease without financial repercussions—potentially allowing them to avoid penalties to their credit and rental history that could make getting back on their feet more challenging. Still, the bill is just one of several policy improvements necessary to help survivors escape abusive situations.

Right now in Pennsylvania, landlords can take action against survivors who break their lease as a means of escape. That could mean a lien against the survivor or an eviction on their credit report. The legislation, HB 1051, introduced by Rep. Madeleine Dean (D-Montgomery County), would allow victims of domestic violence, sexual assault, and stalking to terminate their lease early or request locks be changed if they have “a reasonable fear” that they will continue to be harmed while living in their unit. The bipartisan bill, which would amend the state’s Landlord and Tenant Act, requires survivors to give at least 30 days’ notice of their intent to be released from the lease.

Research shows survivors often return to or delay leaving abusive relationships because they either can’t afford to live independently or have little to no access to financial resources. In fact, a significant portion of homeless women have cited domestic violence as the leading cause of homelessness.

“As a society, we get mad at survivors when they don’t leave,” Kim Pentico, economic justice program director of the National Network to End Domestic Violence (NNEDV), told Rewire. “You know what, her name’s on this lease … That’s going to impact her ability to get and stay safe elsewhere.”

“This is one less thing that’s going to follow her in a negative way,” she added.

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Pennsylvania landlords have raised concerns about the law over liability and rights of other tenants, said Ellen Kramer, deputy director of program services at the Pennsylvania Coalition Against Domestic Violence, which submitted a letter in support of the bill to the state House of Representatives. Lawmakers have considered amendments to the bill—like requiring “proof of abuse” from the courts or a victim’s advocate—that would heed landlord demands while still attempting to protect survivors.

But when you ask a survivor to go to the police or hospital to obtain proof of abuse, “it may put her in a more dangerous position,” Kramer told Rewire, noting that concessions that benefit landlords shift the bill from being victim-centered.

“It’s a delicate balancing act,” she said.

The Urban Affairs Committee voted HB 1051 out of committee on May 17. The legislation was laid on the table on June 23, but has yet to come up for a floor vote. Whether the bill will move forward is uncertain, but proponents say that they have support at the highest levels of government in Pennsylvania.

“We have a strong advocate in Governor Wolf,” Kramer told Rewire.

Financial Abuse in Its Many Forms

Economic violence is a significant characteristic of domestic violence, advocates say. An abuser will often control finances in the home, forcing their victim to hand over their paycheck and not allow them access to bank accounts, credit cards, and other pecuniary resources. Many abusers will also forbid their partner from going to school or having a job. If the victim does work or is a student, the abuser may then harass them on campus or at their place of employment until they withdraw or quit—if they’re not fired.

Abusers may also rack up debt, ruin their partner’s credit score, and cancel lines of credit and insurance policies in order to exact power and control over their victim. Most offenders will also take money or property away from their partner without permission.

“Financial abuse is so multifaceted,” Pentico told Rewire.

Pentico relayed the story of one survivor whose abuser smashed her cell phone because it would put her in financial dire straits. As Pentico told it, the abuser stole her mobile phone, which was under a two-year contract, and broke it knowing that the victim could not afford a new handset. The survivor was then left with a choice of paying for a bill on a phone she could no longer use or not paying the bill at all and being turned into collections, which would jeopardize her ability to rent her own apartment or switch to a new carrier. “Things she can’t do because he smashed her smartphone,” Pentico said.

“Now the general public [could] see that as, ‘It’s a phone, get over it,'” she told Rewire. “Smashing that phone in a two-year contract has such ripple effects on her financial world and on her ability to get and stay safe.”

In fact, members of the public who have not experienced domestic abuse may overlook financial abuse or minimize it. A 2009 national poll from the Allstate Foundation—the philanthropic arm of the Illinois-based insurance company—revealed that nearly 70 percent of Americans do not associate financial abuse with domestic violence, even though it’s an all-too-common tactic among abusers: Economic violence happens in 98 percent of abusive relationships, according to the NNEDV.

Why people fail to make this connection can be attributed, in part, to the lack of legal remedy for financial abuse, said Carol Tracy, executive director of the Women’s Law Project, a public interest law center in Pennsylvania. A survivor can press criminal charges or seek a civil protection order when there’s physical abuse, but the country’s legal justice system has no equivalent for economic or emotional violence, whether the victim is married to their abuser or not, she said.

Some advocates, in lieu of recourse through the courts, have teamed up with foundations to give survivors individual tools to use in economically abusive situations. In 2005, the NNEDV partnered with the Allstate Foundation to develop a curriculum that would teach survivors about financial abuse and financial safety. Through the program, survivors are taught about financial safety planning including individual development accounts, IRA, microlending credit repair, and credit building services.

State coalitions can receive grant funding to develop or improve economic justice programs for survivors, as well as conduct economic empowerment and curriculum trainings with local domestic violence groups. In 2013—the most recent year for which data is available—the foundation awarded $1 million to state domestic violence coalitions in grants that ranged from $50,000 to $100,000 to help support their economic justice work.

So far, according to Pentico, the curriculum has performed “really great” among domestic violence coalitions and its clients. Survivors say they are better informed about economic justice and feel more empowered about their own skills and abilities, which has allowed them to make sounder financial decisions.

This, in turn, has allowed them to escape abuse and stay safe, she said.

“We for a long time chose to see money and finances as sort of this frivolous piece of the safety puzzle,” Pentico told Rewire. “It really is, for many, the piece of the puzzle.”

Public Policy as a Means of Economic Justice

Still, advocates say that public policy, particularly disparate workplace conditions, plays an enormous role in furthering financial abuse. The populations who are more likely to be victims of domestic violence—women, especially trans women and those of color—are also the groups more likely to be underemployed or unemployed. A 2015 LGBT Health & Human Services Network survey, for example, found that 28 percent of working-age transgender women were unemployed and out of school.

“That’s where [economic abuse] gets complicated,” Tracy told Rewire. “Some of it is the fault of the abuser, and some of it is the public policy failures that just don’t value women’s participation in the workforce.”

Victims working low-wage jobs often cannot save enough to leave an abusive situation, advocates say. What they do make goes toward paying bills, basic living needs, and their share of housing expenses—plus child-care costs if they have kids. In the end, they’re not left with much to live on—that is, if their abuser hasn’t taken away access to their own earnings.

“The ability to plan your future, the ability to get away from [abuse], that takes financial resources,” Tracy told Rewire. “It’s just so much harder when you don’t have them and when you’re frightened, and you’re frightened for yourself and your kids.”

Public labor policy can also inhibit a survivor’s ability to escape. This year, five states, Washington, D.C., and 24 jurisdictions will have passed or enacted paid sick leave legislation, according to A Better Balance, a family and work legal center in New York City. As of April, only one of those states—California—also passed a state paid family leave insurance law, which guarantees employees receive pay while on leave due to pregnancy, disability, or serious health issues. (New Jersey, Rhode Island, Washington, and New York have passed similar laws.) Without access to paid leave, Tracy said, survivors often cannot “exercise one’s rights” to file a civil protection order, attend court hearings, or access housing services or any other resource needed to escape violence.

Furthermore, only a handful of state laws protect workers from discrimination based on sex, sexual orientation, gender identity, and pregnancy or familial status (North Carolina, on the other hand, recently passed a draconian state law that permits wide-sweeping bias in public and the workplace). There is no specific federal law that protects LGBTQ workers, but the U.S. Employment Opportunity Commission has clarified that the Civil Rights Act of 1964 does prohibit discrimination based on gender identity and sexual orientation.

Still, that doesn’t necessarily translate into practice. For example, the National Center for Transgender Equality found that 26 percent of transgender people were let go or fired because of anti-trans bias, while 50 percent of transgender workers reported on-the-job harassment. Research shows transgender people are at a higher risk of being fired because of their trans identity, which would make it harder for them to leave an abusive relationship.

“When issues like that intersect with domestic violence, it’s devastating,” Tracy told Rewire. “Frequently it makes it harder, if not impossible, for [victims] to leave battering situations.”

For many survivors, their freedom from abuse also depends on access to public benefits. Programs like Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), the child and dependent care credit, and earned income tax credit give low-income survivors access to the money and resources needed to be on stable economic ground. One example: According to the Center on Budget and Policy Priorities, where a family of three has one full-time nonsalary worker earning $10 an hour, SNAP can increase their take-home income by up to 20 percent.

These programs are “hugely important” in helping lift survivors and their families out of poverty and offset the financial inequality they face, Pentico said.

“When we can put cash in their pocket, then they may have the ability to then put a deposit someplace or to buy a bus ticket to get to family,” she told Rewire.

But these programs are under constant attack by conservative lawmakers. In March, the House Republicans approved a 2017 budget plan that would all but gut SNAP by more than $150 million over the next ten years. (Steep cuts already imposed on the food assistance program have led to as many as one million unemployed adults losing their benefits over the course of this year.) The House GOP budget would also strip nearly $500 billion from other social safety net programs including TANF, child-care assistance, and the earned income tax credit.

By slashing spending and imposing severe restrictions on public benefits, politicians are guaranteeing domestic violence survivors will remain stuck in a cycle of poverty, advocates say. They will stay tethered to their abuser because they will be unable to have enough money to live independently.

“When women leave in the middle of the night with the clothes on their back, kids tucked under their arms, come into shelter, and have no access to finances or resources, I can almost guarantee you she’s going to return,” Pentico told Rewire. “She has to return because she can’t afford not to.”

By contrast, advocates say that improving a survivor’s economic security largely depends on a state’s willingness to remedy what they see as public policy failures. Raising the minimum wage, mandating equal pay, enacting paid leave laws, and prohibiting employment discrimination—laws that benefit the entire working class—will make it much less likely that a survivor will have to choose between homelessness and abuse.

States can also pass proactive policies like the bill proposed in Pennsylvania, to make it easier for survivors to leave abusive situations in the first place. Last year, California enacted a law that similarly allows abuse survivors to terminate their lease without getting a restraining order or filing a police report permanent. Virginia also put in place an early lease-termination law for domestic violence survivors in 2013.

A “more equitable distribution of wealth is what we need, what we’re talking about,” Tracy told Rewire.

As Pentico put it, “When we can give [a survivor] access to finances that help her get and stay safe for longer, her ability to protect herself and her children significantly increases.”

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.