A Global Impact: Multipurpose Prevention Technologies

Yukti Malhotra

While women have made huge strides in the social, economic, and political spheres, our most fundamental right—the right to control our reproductive health—remains in serious jeopardy all over the world. Thanks to exciting new Multipurpose Prevention Technologies (MPTs), we have the potential to revolutionize a woman’s control over her reproductive life.

Last month marked the hundredth anniversary of International Women’s Day. It was a time to celebrate women’s advancements as well as a time to reflect over the inequalities we’ve faced historically and continue to face today. While women have made huge strides in the social, economic, and political spheres, our most fundamental right—the right to control our reproductive health—remains in serious jeopardy all over the world. We have to continue to build a future that ensures access to safe, effective, appropriate, and acceptable ways for each woman to protect her health and control her fertility.

Thanks to exciting new Multipurpose Prevention Technologies (MPTs), we have the potential to revolutionize a woman’s control over her reproductive life. MPTs are combinations of devices (e.g., cervical barriers and vaginal rings), drugs, vaccines, and gels. They’re designed to meet different reproductive health needs, and can be paired differently to prevent unplanned pregnancy, sexually transmitted infections including HIV, and other reproductive tract infections. For example, a single-size cervical barrier could potentially prevent pregnancy as well as deliver an HIV-preventing microbicide. Globally, MPTs would limit the incidence of unsafe abortion and childbearing by curbing the number of unintended births. As a result, they would improve the health and survival of both mother and child. This is no ordinary achievement. In 2008, expanding contraceptive access averted 230,000 maternal deaths and 1.2 million infant deaths. Accessible and easy to use, MPTs would provide a sustainable reproductive care option for many women worldwide.

It’s no surprise that MPTs hold great promise for developing countries. Varied and versatile, they would mediate the scarce reproductive services and fractured healthcare systems common to the poorest and remotest regions. MPTs would make families more healthy, productive, and prosperous where poor maternal health and unwanted pregnancies hinder stability and growth. In short, they’re weapons in the war against poverty.

Unfortunately, anti-choice groups are waging their own war—a war on women worldwide. Recently, the House passed a Continuing Resolution that predicts dire consequences for poor women and jeopardizes MPTs’ potential to aid development. The resolution restricts access to the contraceptive options that MPTs provide. It eliminates funding for the United Nations Population Fund and cuts U.S. funding for international family planning by 15%, when our share of family planning efforts far exceeds $1 billion! It also cuts funding for global HIV/AIDS assistance. Sadly, poor women would be disproportionately affected by these policies. Around 99% of maternal and infant mortality and 95% of HIV/AIDS cases occur in the developing world. With every $100 million in funding cuts, there would be six million fewer women receiving contraceptive services, 800,000 more unplanned births, 600,000 more unsafe abortions, and 5,000 more maternal deaths. Effectively, anti-choice groups would be robbing these vulnerable women of the reproductive care they need and deserve.

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To champions of women’s rights (that is, human rights): It’s time to act. We must create an environment that increases access to safe and effective reproductive technologies and supports reproductive healthcare at home and abroad. Let’s make this a milestone in women’s history. To learn more about MPTs, visit the Coalition Advancing Multipurpose Innovations.

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.

Analysis Law and Policy

Patel Oral Arguments Suggest a Dangerous Precedent for Prosecuting Pregnant People

Jessica Mason Pieklo

Attorneys for the State of Indiana argued it is entirely reasonable for the state to bring felony charges against women who try and terminate their own pregnancies.

Read our other articles on the Purvi Patel case here.

Almost three years ago, the State of Indiana first charged Purvi Patel with both feticide and neglect of a dependent following Patel’s home delivery of what state doctors testified was a 25-week-old fetus. Today, there is still no clear picture of the events leading up to those charges. Based on the conflicting evidence presented at Patel’s seven-day trial, it’s not clear what Patel knew about her pregnancy, including how far along she was. It’s not clear what exactly happened that day in Patel’s bathroom. And, most importantly, there is no clear picture of whether the delivery resulted in a live birth.

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But on Monday, lawyers from the state Attorney General’s Office argued to the Indiana Court of Appeals that none of those unknowns matter. Patel’s charges of feticide for unlawfully terminating her pregnancy and neglecting a live dependent were not contradictory. Quite simply, argued Indiana Deputy Attorney General Ellen Meilaender, if there’s evidence that a person’s conduct contributed to the death of a fetus or a severely prematurely infant born alive that then dies, that person faces possible felony prosecution both for feticide and criminal neglect of a dependent—setting a disturbing potential precedent for pregnant people throughout the state.

The Indiana feticide statute makes it a felony for a person to “knowingly or intentionally terminate a human pregnancy with an intention other than to produce a live birth or to remove a dead fetus.” The statute is silent on whether a self-induced abortion falls under this category. Indiana prosecutors argue that it does and told the appeals court Monday that the jury verdict against Patel proved them right.

The state made a similar argument with Patel’s conviction for felony neglect of a dependent. According to the state, by taking abortion-inducing drugs, Patel created a situation that put her “dependent”—in other words, her fetus—in harm’s way. Once delivered alive, the state argued, Patel had a legal duty to immediately seek medical attention on its behalf, including clamping her umbilical cord immediately after delivery to prevent neonatal blood loss and calling 9-1-1 for emergency care. It made no difference, prosecutors said, that the medical evidence was contradictory as to whether there was a live birth at all, or what, if anything, Patel understood was happening at the time of the delivery.

Patel’s attorneys may disagree with the inferences made by the jury, state attorneys argued, but that doesn’t mean the law grants the court grounds to overturn the jury verdict.

It wasn’t clear to me at the end of oral arguments that the three-judge panel was buying the State’s argument. The judges pushed Meilaender hard on where the law should draw the line between taking nonprescribed abortion medications that produce a live birth where the baby then dies—as the state argued happened here—to drinking whiskey, smoking cigarettes, or taking any other host of actions that may help contribute to a miscarriage. The judges seemed to agree that it would be excessive to prosecute pregnant people for smoking, for example. The judges also appeared skeptical about the argument that the feticide statute doesn’t require the fetus to die in utero, and that even a live birth can and should be prosecuted under this statute if the accused person’s original intent was to terminate a pregnancy outside Indiana’s stringent legal abortion requirements.

But it also wasn’t clear they bought the argument of Patel’s attorney, Lawrence Marshall, that the state hadn’t met its burden of proof when it convicted her. Marshall stammered to keep the judges on point, refusing to answer whether federal constitutional precedent, from Roe v. Wade to Planned Parenthood v. Casey, would protect many other people from unchecked pregnancy policing under feticide laws. (Spoiler: The simple answer is no—as Tennessee, Mississippi, Alabama, and Arkansas, to name a few, show).

The heart of the state’s negligence case against Patel rests on her alleged failure to seek care for a live birth. Yet Marshall could not specifically and directly answer the judges’ concerns that Patel, after allegedly cutting the umbilical cord during delivery, should have also immediately clamped or kinked it to prevent any blood loss to the fetus she just delivered. He did not note that it is unreasonable to expect any woman immediately following an extremely premature delivery to have the presence of mind to do such things, lest she face felony prosecution. He tried to point out that there was medical testimony at trial that at 25 weeks, severely prematurely born infants have only modest survival rates even when born at hospitals and immediately transferred to neonatal intensive care units, and tried to argue the state couldn’t prove that Patel had any idea a live birth had even happened. But all those counters appeared to fall flat on a panel of judges clearly willing to consider, and perhaps even accept, that Patel’s failure to kink her umbilical cord and call 9-1-1 immediately post-delivery was sufficient to convict her for felony neglect of a dependent.

Throughout the trial and the appeal, the state compensated for its lack of direct evidence about the situation by trying to redirect the jury’s focus to Patel’s “character,” which, prosecutors argued, helped inform the decision to convict her. Patel was in a relationship with a married man. Evidence at trial showed she had been texting back and forth with a friend concerning the pregnancy and her desire to terminate it, in part because of fears her conservative Hindu family would not support her. That’s both sexually provocative and naive, argued the state in its appellate brief—provocative because she was acting outside religious and social norms, and naive because “family would have loved her regardless and would have welcomed the baby, as it is their religious belief to love a child even if born out of wedlock and their religion is opposed to killing anyone or anything.”

Meanwhile, the state argued, the evidence that should be weighed in Patel’s favor did not matter. That included evidence at trial that showed Patel believed she was only about 12 weeks pregnant—not about 25 weeks—when she took the unprescribed abortifacient. Not important, argued the state. All that matters is her fetus was old enough to fall outside Indiana’s limit on 20-week abortions. Evidence at trial showed that Patel tried, ultimately unsuccessfully, to navigate Indiana’s web of anti-choice restrictions before ordering abortion-inducing medications online; but that just demonstrates Patel had the right criminal intent to support the jury’s conviction, said Meilaender, not that those regulations are difficult for non-lawyers to navigate on their own.

In other words, argued Meilaender, the details that should normally be necessary to support a criminal conviction—details such as what Patel knew, and when—just don’t matter in this case.

Those details do matter. That’s why the U.S. Court of Appeals for the Ninth Circuit rejected nearly identical arguments in the prosecution of Jenni Linn McCormack, an Idaho woman who also terminated a pregnancy and was criminally prosecuted for it. Expecting patients to understand the intricacies of abortion restrictions or face criminal prosecution at its very core unduly burdens abortion rights, that court ruled.

It will likely be months before the Indiana Court of Appeals issues its opinion. And I’m not going to make any guesses about how this case turns out. But I will say that, despite all the unknowns in the Patel case, there are plenty of knowns that ultimately affect Patel and pregnant people in Indiana as a whole.

We know that Indiana law does not mandate sex education be taught in its schools. The Indiana Department of Education recommends its inclusion as part of a school’s comprehensive health education program. But that’s it. And for those schools that decide to offer some form of sex ed, there’s no requirement that the information provided be unbiased and medically accurate, let alone do anything other than stress abstinence-only sex ed. And of course, parents in Indiana have the option of opting out of sex ed entirely for their children should they so choose.

We also know that legal abortion in Indiana is extensively and severely restricted. First, any person seeking an abortion must receive state-mandated counseling that includes information designed to discourage the patient from having an abortion. That counseling must be done in person. Indiana law then requires a patient to wait an additional 18 hours after that counseling session before an abortion can be performed. That means, effectively, patients must make two separate trips to an abortion clinic to have the procedure. A patient must also undergo an ultrasound before obtaining an abortion and during that ultrasound the provider must offer her the option to view the ultrasound image.

Indiana law also prohibits the use of telemedicine for medication abortion. Also, Indiana bans abortions after 20 weeks, with only a very narrow exception of when the patient’s life or physical health is at risk.

And if that patient can navigate the consent and waiting period requirements, how will they pay for the procedure? In Indiana, abortion is covered in private insurance policies only in cases of life endangerment, rape, incest, or the severely compromised health of the pregnant person. Individuals have the option of buying a separate abortion policy, but that, of course, is at additional cost.

What do Indiana’s sex ed requirements and abortion restrictions have to do with Patel’s conviction and appeal? Everything. Just like the fact that Patel, like Bei Bei Shuai before her, is not white and is not wealthy. A lack of comprehensive sex education means it’s increasingly likely other patients will, like Patel, have very little apparent understanding of the pregnancy process, particularly early on in pregnancy when indicators such as a missed period can be mixed. An increasingly draconian set of abortion restrictions means more and more patients like Patel will find themselves unable to access a legal provider or afford an abortion at all, which means that more and more patients like Patel will be forced into either attempting to self-terminate an unwanted pregnancy or carrying it to term.

Attorneys for the State of Indiana tried to tone down the “canary in a coal mine” aspect to Patel’s conviction. But there really is no denying it. During Monday’s arguments, they were pressing for the right to bring felony charges against women who terminate their own pregnancies. They insisted those prosecutions are exactly what the Indiana legislature intended when passing its feticide statute and further, such prosecutions advanced the state’s “significant” interest in protecting “unborn human life.”

Combine those arguments with the unavailability of comprehensive sex ed and the anti-choice restrictions in Indiana, and it’s clear that Patel’s case is absolutely a test case in the limits, if any, of state power to regulate pregnancies and their outcomes. Should Patel’s conviction be upheld, then the courts will have sent a very strong message to the the people of Indiana: The state expects and demands a healthy, live birth with each pregnancy, and failure to produce one could result in felony charges.