News Maternity and Birthing

At Triennial Conference, A Call To Strengthen Midwifery, Maternal Health Globally

Brenda Zulu

The International Confederation of Midwives (ICM), the worldwide professional association of midwives, is holding their first meeting in Africa this week, in Durban, South Africa. The focus is on ensuring the women of the world have safe pregnancies and increased access to medical services.

The International Confederation of Midwives (ICM), the worldwide professional association of midwives, is holding their first meeting in Africa this week, in Durban, South Africa. The theme of the 29th Triennial Congress is “Midwives talking the ‘Big 5’ globally”, referring to the five major health concerns for childbearing women, and for midwives in Africa.

In her remarks at the opening plenary, ICM President Bridget Lynch noted the important role midwives play in protecting the welfare of childbearing families and meeting the Millennium Development Goals (MDGs).

“We would like to have a midwife attending to every woman giving birth as a midwife is a midwife everywhere,” said Lynch. She observed that midwifery was the first health care profession that established educational standards. She noted, however, that midwifery educational standards differed from country to country and made a call to action to strengthen midwifery globally and the educational capacity.

In highlighting key events taking place at the congress, Lynch pointed to the launch of a major global report, the State of the World’s Midwifery 2011: Delivering Health, Saving Lives, led by the UN Population Fund (UNFPA), with contributions from 26 agencies ICM. The conference programme was organized by the Society of Midwives’ of South Africa, intended to strengthen the capacity of midwives to tackle five major health issues for childbearing women:

Like This Story?

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

Donate Now

  1. Lack of prenatal care

  2. HIV/AIDS, which has devastated communities and healthcare systems

  3. Nonpregnancy-related infections and diseases, such as malaria and tuberculosis

  4. Hypertension

  5. Sepsis during pregnancy, after abortion and after childbirth

In her welcome remarks, Deputy Health Minister of South Africa Dr. Gwen Ramakgoba observed that there was need for midwives to enable women of the world to have safe pregnancies and ensure access to medical services for women in an effort to promote safe motherhood.

One of the greatest gifts of midwifery is to hear the cry of the baby and see a smile on the mother,” said Dr Ramakgoba.

She urged midwives to listen carefully to mothers, and learn more about what works for them in the use of family planning. In terms of midwifery practice, she said there was need to improve the workplace environment and also improve staff retention. She called on the assembly to monitor the migration of skilled midwives and nurses to better paying jobs in cities or developed countries. She noted that one of the key factors hampering progress in reducing maternal mortality rates was the inability to retain skilled workers in the most affected regions.

ICM also recognized the achievements of three midwives during the opening plenary. One of those recognized was Madina Rashidi, who received the “Save the Children Everyone Midwife Award 2011.” Rashidi is a community midwife in Qarqin, Afghanstan, a rural district in Jawzjan province, Afghanistan. She was the only woman living in her district who had completed high school and her community selected her to attend midwifery school. In 2009, she returned to the village where she is the only midwife in the only health centre, providing coverage 24 hours a day. Most women in her region deliver at home either with the help of a relative, a traditional birth attendant or alone. Rashidi changed centuries of tradition, persuading men to allow their wives to come to the health centre to give birth. Through her tireless efforts, women are increasingly coming for antenatal care, assisted childbirth and postnatal care.

Other honorees are Catherine Oluwatoyi Ojo who works in Northern Nigeria, who received another ICM/Save the Children EVERY ONE Midwife Award 2011; Dr Christina Mudokwenyu-Rawdon of Zimbabwe, who received the Marie Goubran Award in recognition of her leadership in midwifery education.

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 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.

Commentary Sexual Health

Don’t Forget the Boys: Pregnancy and STI Prevention Efforts Must Include Young Men Too

Martha Kempner

Though boys and young men are often an afterthought in discussions about reproductive and sexual health, two recent studies make the case that they are in need of such knowledge and that it may predict when and how they will parent.

It’s easy to understand why so many programs and resources to prevent teen pregnancy and sexually transmitted infections (STIs) focus on cisgender young women: They are the ones who tend to get pregnant.

But we cannot forget that young boys and men also feel the consequences of early parenthood or an STI.

I was recently reminded of the need to include boys in sexual education (and our tendency not to) by two recent studies, both published in the Journal of Adolescent Health. The first examined young men’s knowledge about emergency contraception. The second study found that early fatherhood as well as nonresident fatherhood (fathers who do not live with their children) can be predicted by asking about attitudes toward pregnancy, contraception, and risky sexual behavior. Taken together, the new research sends a powerful message about the cost of missed opportunities to educate boys.

Like This Story?

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

Donate Now

The first study was conducted at an adolescent medicine clinic in Aurora, Colorado. Young men ages 13 to 24 who visited the clinic between August and October 2014 were given a computerized survey about their sexual behavior, their attitudes toward pregnancy, and their knowledge of contraception. Most of the young men who took the survey (75 percent) had already been sexually active, and 84 percent felt it was important to prevent pregnancy. About two-thirds reported having spoken to a health-care provider about birth control other than condoms, and about three-quarters of sexually active respondents said they had spoken to their partner about birth control as well.

Yet, only 42 percent said that they knew anything about emergency contraception (EC), the only method of birth control that can be taken after intercourse. Though not meant to serve as long-term method of contraception, it can be very effective at preventing pregnancy if taken within five days of unprotected sex. Advance knowledge of EC can help ensure that young people understand the importance of using the method as soon as possible and know where to find it.

Still, the researchers were positive about the results. Study co-author Dr. Paritosh Kaul, an associate professor of pediatrics at the University of Colorado School of Medicine, told Kaiser Health News that he was “pleasantly surprised” by the proportion of boys and young men who had heard about EC: “That’s two-fifths of the boys, and … we don’t talk to boys about emergency contraception that often. The boys are listening, and health-care providers need to talk to the boys.”

Even though I tend to be a glass half-empty kind of person, I like Dr. Kaul’s optimistic take on the study results. If health-care providers are broadly neglecting to talk to young men about EC, yet about 40 percent of the young men in this first study knew about it anyway, imagine how many might know if we made a concerted effort.

The study itself was too small to be generalizable (only 93 young men participated), but it had some other interesting findings. Young men who knew about EC were more likely to have discussed contraception with both their health-care providers and their partners. While this may be an indication of where they learned about EC in the first place, it also suggests that conversations about one aspect of sexual health can spur additional ones. This can only serve to make young people (both young men and their partners) better informed and better prepared.

Which brings us to our next study, in which researchers found that better-informed young men were less likely to become teen or nonresident fathers.

For this study, the research team wanted to determine whether young men’s knowledge and attitudes about sexual health during adolescence could predict their future role as a father. To do so, they used data from the National Longitudinal Study of Adolescent Health (known as Add Health), which followed a nationally representative sample of young people for more than 20 years from adolescence into adulthood.

The researchers looked at data from 10,253 young men who had completed surveys about risky sexual behavior, attitudes toward pregnancy, and birth control self-efficacy in the first waves of Add Health, which began in 1994. The surveys asked young men to respond to statements such as: “If you had sexual intercourse, your friends would respect you more;” “It wouldn’t be all that bad if you got someone pregnant at this time in your life;” and “Using birth control interferes with sexual enjoyment.”

Researchers then looked at 2008 and 2009 data to see if these young men had become fathers, at what age this had occurred, and whether they were living with their children. Finally, they analyzed the data to determine if young men’s attitudes and beliefs during adolescence could have predicted their fatherhood status later in life.

After controlling for demographic variables, they found that young men who were less concerned about having risky sex during adolescence were 30 percent more likely to become nonresident fathers. Similarly, young men who felt it wouldn’t be so bad if they got a young woman pregnant had a 20 percent greater chance of becoming a nonresident father. In contrast, those young men who better understood how birth control works and how effective it can be were 28 percent less likely to become a nonresident father.9:45]

Though not all nonresident fathers’ children are the result of unplanned pregnancies, the risky sexual behavior scale has the most obvious connection to fatherhood in general—if you’re not averse to sexual risk, you may be more likely to cause an unintended pregnancy.

The other two findings, however, suggest that this risk doesn’t start with behavior. It starts with the attitudes and knowledge that shape that behavior. For example, the results of the birth control self-efficacy scale suggest that young people who think they are capable of preventing pregnancy with contraception are ultimately less likely to be involved in an unintended pregnancy.

This seems like good news to me. It shows that young men are primed for interventions such as a formal sexuality education program or, as the previous study suggested, talks with a health-care provider.

Such programs and discussion are much needed; comprehensive sexual education, when it’s available at all, often focuses on pregnancy and STI prevention for young women, who are frequently seen as bearing the burden of risky teen sexual behavior. To be fair, teen pregnancy prevention programs have always suffered for inadequate funding, not to mention decades of political battles that sent much of this funding to ineffective abstinence-only-until-marriage programs. Researchers and organizations have been forced to limit their scope, which means that very few evidence-based pregnancy prevention interventions have been developed specifically for young men.

Acknowledging this deficit, the Centers for Disease Control and Prevention and the Office of Adolescent Health have recently begun funding organizations to design or research interventions for young men ages 15 to 24. They supported three five-year projects, including a Texas program that will help young men in juvenile justice facilities reflect on how gender norms influence intimate relationships, gender-based violence, substance abuse, STIs, and teen pregnancy.

The availability of this funding and the programs it is supporting are a great start. I hope this funding will solidify interest in targeting young men for prevention and provide insight into how best to do so—because we really can’t afford to forget about the boys.