Get Real! Myths & Realities of Bleeding with First Intercourse

Heather Corinna

There has been little scientific research on the incidence of bleeding after first intercourse, and it doesn't have any real medical relevance.

This column is published in partnership with Scarleteen.

go_warriors_cc asks:

How long after a girl’s first time
should they bleed for and how heavy should they bleed?

Heather Corinna replies:

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

There aren’t any "shoulds"
here. Not all women bleed with first-time intercourse or other kinds of vaginal
entry: in fact, most don’t. Why some women do — and for how long they do —
and some don’t also varies.

As to how many women do and don’t
bleed after first intercourse, very little scientific study has been done on
that. That’s unsurprising since bleeding from one specific act of intercourse
(rather than it happening with frequency) often doesn’t have any real medical
relevance, and healthcare providers and sex educators — if we’ve done our
homework — also pretty much have the answers we need already. One study which
was done, cited by my friend Hanne Blank in her book, Virgin: The Untouched
, was an informal one in 1998 published in the British Medical
by Dr. Sara Patterson-Brown. She found that at least 63 percent of the
women she asked about bleeding and first intercourse reported that they did not
experience bleeding. We say at least because in her study, some of the women
she asked about it couldn’t remember. (And if that surprises you, please
understand that the idea no one will ever forget every detail of their first
time simply doesn’t hold up to reality: some people, especially over time, wind
up remembering little to nothing about it at all.)

We know that some women have
bleeding and that others have none. For those who do, how much is something
else that varies, largely because what causes the bleeding varies. Some women
who have bleeding will only lightly spot for a few hours, others will have
near-period level bleeding for a day or two, some more or for even longer.

For the most part, just like
bleeding from any other part of your body, bleeding that comes with or follows intercourse
or any other kind of sex is due to an injury. How can injury happen during sex?
In a few different ways:

1.) If a female-bodied person isn’t aroused (sexually excited) enough, or at all,
before and during entry, often the vaginal opening and vagina will have not
loosened and/or self-lubricated enough for entry or intercourse to be
pleasurable for her or truly workable. In other words, it may be possible,
in that their partner can manage to force their penis (or whatever else) into
the vagina, but it often won’t feel good to that receptive partner, and often
results in tearing of or abrasions to the tissues of the vulva, vagina or
cervix. Suffice it to say, if a woman isn’t consenting to sex at all, but is
sexually assaulted, bleeding is very common for this reason.

2.) When a partner is too rough. If a partner is too rough or
forceful with their penis, fingers or a sex toy, whether a woman is aroused or
not, that can cause injury and bleeding.

3.) Because of an infection or other medical condition. For
instance, the sexually transmitted infection Chlamydia can sometimes cause
bleeding with intercourse. The STIs Gonhorrhea or Trichomoniasis can also cause
bleeding. So can endometriosis, fibroid tumors, vaginitis, yeast infections,
uterine or cervical polyps, cervical dysplasia and other kinds of cervicitis,
and more rarely, cervical cancer. Because of cervical tenderness during
pregnancy, some pregnant women experience bleeding from intercourse, too.
Another possibility for women much older than you are is that menopause is
playing a part: with menopause decreasing levels of estrogen thin the vaginal
walls, making them less flexible and resilient.

4.) If the corona or hymen is still in the process of
wearing away or has worn away very little, and that intercourse or entry tears
(in which case this is bleeding usually actually due to #2), stretches or
erodes it. This is the reason people tend to most commonly think is why vaginal
bleeding with intercourse happens: some people even think it’s the only reason.
Age can be a big factor when this is the cause. Because this tissue wears away
over time, the younger a woman or girl is when she has intercourse the more
likely it is that there’s more of the corona to wear away, and the more likely
is it there will be some bleeding. Consider that in our modern day, for as much
as you hear adults talking about how young people having sex in their teens and
twenties are, many women in history, and in some places still, had first
intercourse (and marriage) at even younger ages than now. So, when it comes to
specifically hymenal bleeding, it’s something we likely see less of now than we
did, 500 or more years ago. As well, arousal and lubrication is an issue with
this one, too. The corona is usually very stretchy and flexible, so even
someone who has one that’s not yet eroded enough to be totally out of the way
can have pleasurable sex without bleeding from that tissue when they are
aroused and lubricated enough, be that lubrication form their own bodies or
from a bottle. In that case, the corona often just slides to the side of the
vaginal opening a lot like the inner labia stay to the side during intercourse.

Based on what we know from medicine,
and what sex educators know from talking to people about this, the first three
situations are the most common causes of vaginal bleeding, not the last.

A lot of people do mistakenly think
that bleeding is a "must" or always happens, and that when it does
it’s always about the hymen/corona and one big reason for that has to do with
outdated cultural ideas more than anything else. The same people also often
think first-time intercourse usually or always will be — or even should be —
painful. And that’s not true, either. The most common reasons for intercourse
being painful are also often 1 – 3 above, not 4.

To understand why people think the
way they do about this, it’s helpful to consider history. We get asked what
you’re asking a lot, and have a lot of women writing in worried that they
didn’t bleed, and also hear from male partners who don’t trust the sexual
history of female partners who didn’t bleed. So, I’m going to dig in here.

For a very long time, before there
was the better understanding of women’s bodies and sexuality we have in this
century and some of the last, it was near-universally thought that women who
had not had intercourse or any other kind of vaginal entry had a seal on the
front of their vaginas (the hymen) which was only "broken" by their
first sexual partner. The idea was that when that was broken — people still
talk about "popping the cherry" and this is where that comes from —
a woman would bleed, and if a woman did not bleed during first
intercourse, that’s because someone else "broke her seal" already.

Some of this was based in ignorance,
and some in seriously hardcore sexism and viewing women, and our bodies, as
property. The idea that women needed to prove a male partner or spouse got what
they paid for (through most of history, marriage involved financial exchanges
and benefits) when they married a virgin was the norm for most of history in
many cultures, most certainly including Western culture. The idea that bleeding
proved a man had truly "broken in" a woman via intercourse was, and
sometimes still is, popular. The idea that "breaking in" or
"deflowering" a woman was about male power and prowess, same deal.
Historically, there have also been some issues of cultural expectations for men
and women alike afoot around this, like the notion that a marriage wasn’t
really bonafide unless it had been consummated, so blood on the sheets proved a
married couple had had sex.

Some ideas around virginity, first
intercourse and bleeding as proof of virginity also involved paternity. We can
always know at a birth who someone’s mother is, since we can see an infant come
out of her body. What we can’t know just by looking — the paternity tests we
have now weren’t invented until the 1980’s — is who someone’s father is. So,
some of the idea was that so long as you had sex with a virgin, proven by
bleeding or pain with intercourse, you, as a male, could be absolutely certain
that any children that were born were yours.

Lastly, historically, women’s desire
for intercourse or any other kind of sex was largely ignored, sometimes even
considered an impossibility. We always need to understand that for many women
through time, their first sex was actually either their first rape or something
women just did not because they felt a sexual desire to, but because they
understood it was something they had to do for men. If you’re wondering why
women would have sex like that when they didn’t want to, remember that for
many, marriage, or doing what men wanted, was a matter of life or death: for
many women historically (and for some women still in parts of the world),
marriage was the difference between having a place to live and not having one,
between having food to eat or starving.

For most of history, sex was
considered something that men wanted, that was 100% about men, that women
didn’t have any interest in but were obligated to do for men and had little choice
or voice in, especially once they were married. Because of that, and because
historically, first sex for women was not with someone they were in love with
or attracted to, we can also know that for some women who had bleeding at first
intercourse through history, that was because they were not aroused, were
scared, and often sex was everything from only out of obligation to barely
consensual to completely nonconsensual and by force.

Because of all of those kinds of
ideas and cultural precedents, bleeding was usually seen as something that
better well happen, and because sometimes "proof" needed to be shown
that a woman was, in fact, a virgin as she said she was.

Check out this passage from Deuteronomy
22 in the Old Testament
, to get an idea of the weight of virginity
in history, as well as what the consequences for a woman could be if she hadn’t
bled with intercourse:

If any man take a wife, and go in
unto her, and hate her, and give occasions of speech against her, and bring up
an evil name upon her, and say, I took this woman, and when I came to her, I
found her not a maid: Then shall the father of the damsel, and her mother, take
and bring forth the tokens of the damsel’s virginity unto the elders of the
city in the gate. And the damsel’s father shall say unto the elders, I gave my
daughter unto this man to wife, and he hateth her; and, lo, he hath given
occasions of speech against her, saying, I found not thy daughter a maid; and
yet these are the tokens of my daughter’s virginity. And they shall spread the
cloth before the elders of the city. And the elders of that city shall take
that man and chastise him; and they shall amerce him in an hundred shekels of
silver, and give them unto the father of the damsel, because he hath brought up
an evil name upon a virgin of Israel: and she shall be his wife; he may not put
her away all his days.

But if this thing be true, and the
tokens of virginity be not found for the damsel: then they shall bring out the
damsel to the door of her father’s house, and the men of her city shall
stone her with stones that she die
: because she hath wrought folly in
Israel, to play the whore in her father’s house: so shalt thou put evil away
from among you.

The "tokens" they’re
talking about are something like a sheet or wedding garment with a bloodstain,
to "prove" she was, indeed, a virgin. In other words, for many women
in history, proving to be a virgin through blood could literally save their
lives. In some cultures, new brides had to prove they were virgins on their
wedding night by doing things like hanging their sheets outside the next
morning for the whole community to be convinced — by the bloody spot on the
sheet — that they were, indeed, virgins. And to think how much you all worry
about someone seeing a menstrual stain on your pants! At least no one hangs
them out for the neighbors to gawk at.

Trouble is — well, there’s quite a
lot of trouble with that, obviously, but let’s just address the bloody matter
at hand — that idea was, and still is, massively flawed.

The corona (hymen) isn’t actually a
"seal" at all for most women. Rather, it’s thin folds of membrane
that wear away over time (due to hormones, vaginal discharges, menstrual
periods, masturbation and/or general physical activity, as well as partnered
sex), even for those who don’t ever have intercourse at all. Some women are
even born without hymens or with hymens whose appearance is such that you can’t
tell there’s one there at all.

For most women, in childhood, very
small openings to that mambrane start to form and get larger over time, which
is why 12-year-old girls can have menstrual flow, even if they never had any
kind of sex. If those openings didn’t happen, that flow and other vaginal discharges
would get trapped inside. That can happen: some women have resilient hymens,
but that’s rare, and also is a medical problem that requires a minor surgery
(called a hymenectomy), not a normality.

So, plenty of women through history
wound up not bleeding at all, absolutely including women who truly had not had
any kind of sexual partnership before that time. Because not bleeding could
result in things like divorce, a public gynecological examination, being
disowned by family or community or even a stoning or other kind of public
execution, what many women did was fake bleeding. Many older women actually
knew full well, from experience, that this idea that bleeding always happens
with intercourse was a farce, so new brides would often be prepared by other women
on how to fake bleeding in case they didn’t. For instance, brides were often
told how to keep a sponge full of animal blood handy so they could insert it
into their vaginas to create the appearance of vaginal blood, or to sneakily
squeeze it on a sheet in case they didn’t bleed. Other women cut themselves on
purpose to create blood.

Even in relationships or communities
today where bleeding or not isn’t such a dire matter, some women are still
dishonest with friends, family or partners about bleeding because — mostly
because of all this history — they worry something is or was wrong with them
if they didn’t, feel ashamed they didn’t bleed, worry someone will question
that it really was their first time, or feel they need to tell partners they
bled in order to satisfy them.

And of course, because there are
other and more common reasons for vaginal bleeding with intercourse, some women
had bleeding, but it either wasn’t just because of erosion of the corona
during sex, or wasn’t for that reason at all, but was because of things like a
partner being rough, a woman being scared and/or unaroused, or a woman having a
health condition that caused that bleeding. The same is true today.

These are the kinds of historical
sources that the idea bleeding should or must happen come from. These were (and
for those who still have them, still are) really
lousy, creepy and inaccurate ideas and precedents that are hardly respectful of
women, and most certainly didn’t treat women as whole people. They have never
been based in the reality of women’s anatomy or sexual experiences. When it all
comes down to it, they’ve never really been about women at all, but about the
way men and the world at large decided women are or are not valuable based not
only in sexism, but in ignorance about our bodies.

So, what SHOULD happen with first
Ideally, it should start by being
something you (or any other woman, as well as her partner) very much want and
feel ready for and comfortable with as a whole. It should be something that you
only choose to do when a given relationship feels ready for it, including you
and a partner having engaged in other kinds of sex or masturbation together
before so that you both have a good idea of when you are and are not aroused,
what gets you there, and have developed some skills and comfort openly and
honestly communicating about sex together, which certainly includes speaking up
if something hurts or doesn’t feel good, not just quietly suffering in silence
or pretending sex feels good when it doesn’t. As with any other kind of sex, if
it’s something that is in any way painful or uncomfortable, it should be something
you can feel very free to stop or make adjustments with — like adding more
lube, or going back to other sexual activities that get you more turned on —
as needed. Ideally, it’s also an experience that everyone involved enjoys and
feels good about, and where no one is coming to it with the kinds of ideas many
have through history.

Maybe you will (or did) have
bleeding, and maybe you won’t (or didn’t). In either case, that doesn’t tell
us, all by itself, anything about you, your value as a person, the state of
your virginity or your sexual experience.

In the case you do or did have
bleeding, and it was more than spotting, and carried on for more than a couple
of days, or if it happens with intercourse often, checking in with a healthcare
provider is a good idea. As you know now, that bleeding may possibly be due to
a medical condition you need looked into and treated, or an injury from sex you
need treatment for, or just an awareness of why it’s happening so you can find
out how to keep it from happening again.

There’s nothing to be ashamed of
when it comes to bleeding, just like there’s nothing for a guy to be ashamed of
when it comes to his body fluids, but you do always want to do what you can to
avoid injury with sex, just like we want to avoid injury with anything else. If
it does happen, you just clean it up, and then use a menstrual pad if you need
to. If you do (or did) have bleeding, you’ll also want to chill with
intercourse for a few days so that whatever that injury was has a chance to heal.

It probably goes without saying that
the one "should" I’d put in this is that if you do have any of the
inaccurate or value-based ideas about bleeding with first intercourse I talked
about here, I do think you should consider ditching them.

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.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

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.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

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 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.