News Maternity and Birthing

Midwives Fight to Make Their Practice Legal Again in Delaware

Emily Crockett

Currently, in Delaware, it’s effectively illegal for a trained, certified midwife to attend a home birth. A new bill introduced in the state legislature last week aims to change that, and is one example of how a growing movement of midwives is seeking to change inconsistent state laws that often criminalize their practice.

Currently, in Delaware, it’s effectively illegal for a trained, certified midwife to attend a home birth. A new bill introduced in the state legislature last week aims to change that, and is one example of how a growing movement of midwives is seeking to change inconsistent state laws that often criminalize their practice.

Midwifery is not technically forbidden under Delaware state law, advocates told Rewire, but certified professional midwives (CPMs) hired by pregnant women who want to give birth at home face a legal catch-22. CPMs undergo three to five years of training and assessments to become nationally certified, but they still usually need to be licensed in individual states. To get a license in Delaware, midwives have to form a collaborative agreement with a doctor—but no doctor will sign such an agreement, because most malpractice insurers won’t cover CPMs or home births. And if a midwife delivers a baby without obtaining this agreement, she faces a felony charge and a fine of at least $1,000 for the unauthorized practice of medicine. These criminal charges were made explicit last year in a contentious bill that passed last-minute at the end of the session.

“The Department of Health in Delaware wrote rules that make no sense,” Susan Jenkins, steering committee member of the Big Push for Midwives Campaign, told Rewire. There are also only three CPMs in Delaware, Jenkins said, two of whom have been issued cease and desist orders for attending home births and who could face felony charges. (Jenkins is also an attorney who has represented one of those women.) The third CPM did manage to get a collaborative care agreement signed, but that’s because she only works with Amish clients, who generally don’t sue or go to hospitals.

Jenkins noted that the state’s small number of practitioners is mostly due to the harsh regulatory environment, and that more would be likely to practice in the state if they could get licensed. Helping midwives get licensed is the goal of HB 319, sponsored by Rep. Paul Baumbach (D-Newark), which would form a council to write rules and regulations for the practice of midwifery. The Midwife Advisory Council’s rules would be subject to approval by the Board of Medical Licensure and Discipline, and the council would be made up of three CPMs, a certified nurse midwife (a midwife who is also trained as a nurse), an obstetrician, and a pediatrician.

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About 20 midwives, doulas, and expectant mothers lobbied Delaware legislators to support the bill, sharing their stories of successful home births and arguing that mothers should be able to legally choose the birth option they feel is most right for them.

Delaware isn’t the only state where a tangle of old and new laws and regulations has either directly or indirectly outlawed the practice of non-nurse midwifery. According to data from the Big Push for Midwives Campaign, as many as 22 states do not legally authorize CPMs to practice. Midwives won victories most recently in California (where a new law provided for licensure and removed a requirement that midwives be supervised by doctors) and Hawaii (where two bills seen as hostile to midwives were defeated).

Katie Prown, a Big Push for Midwives steering committee member who has worked on pro-CPM campaigns in 19 states, told Rewire that midwife advocacy occupies a strange ideological space: It brings together women from both the pro-choice and anti-choice movements, and it leads to battles in states with either liberal or conservative legislatures. In the latter case, she said, “Whoever the majority party is, the caucus is divided, and we always find supporters [of hostile legislation] owe a lot of their campaign cash to the medical lobby.”

A 2006 battle for pro-midwife legislation in Wisconsin took legislators completely off-guard, Prawn said, because of the strength and breadth of the grassroots movement behind it. “The feedback we got was that this was the first bill in years where people were hearing from literally every single district in the state,” Prawn said. “The most conservative and the most liberal member of the state senate were both sponsoring the bill. Nobody had seen that in years.” The kicker, she said, came when the campaign flooded the halls of the state house with Amish and Mennonite supporters of the bill to flummox opponents who had been invoking the Amish in their arguments.

Critics of midwifery say home births are less safe than hospital births, while midwives point to more favorable research and say studies claiming home births to be unsafe are biased. But regardless of where the scientific consensus ends up, advocates say, there will always be some percentage of women who do not want to deliver in hospitals, and the goal should be making non-hospital births safer, not outlawing them.

“It is just lazy to assume that all the people who choose home birth do so because Ricki Lake told them to,” said Farah Diaz-Tello, staff attorney with National Advocates for Pregnant Women, referring to Lake’s 2008 pro-home birth documentary The Business of Being Born. “They have needs and concerns that aren’t being met in hospitals and birthing centers, and instead of pushing them further to the margins, we need to try to address those needs and make sure that the care they get is as safe as possible.”

Moreover, Diaz-Tello said, since even relatively safe activities will never be 100 percent safe, “safety” is often used as a pretext to carry out other agendas, especially those that end up harming women. States like Texas and Mississippi, for instance, have nearly regulated abortion out of existence in the name of “safety,” she said.

“This is why birth is such a feminist issue and a reproductive rights issue,” Jenkins said. “It’s a choice that women and their families should be able to make.”

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 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.


Anti-Trans Petition Fails to Make November Ballot in Washington State

Nicole Knight Shine

"Washingtonians stood up against discrimination and secured this significant victory—for our state and our nation—ensuring that transgender people and their families will continue to be protected equally under the law," Kris Hermanns, CEO of The Pride Foundation, an LGBTQ advocacy group, wrote on Friday.

LGBTQ rights advocates in Washington state were cheering the news Friday that a discriminatory proposed bathroom measure requiring individuals to use facilities corresponding to their assigned gender at birth failed to qualify for the statewide ballot.

“Washingtonians stood up against discrimination and secured this significant victory—for our state and our nation—ensuring that transgender people and their families will continue to be protected equally under the law,” Kris Hermanns, CEO of the Pride Foundation, an LGBTQ advocacy group, wrote on Friday, after hearing the news.

The measure’s backer, a group called Just Want Privacy, announced Thursday night the petition hadn’t gathered the required 246,000 signatures to go before voters in November.

Just Want Privacy launched the petition, known as I-1515, shortly after the state Human Rights Commission, in a December rule, affirmed a 2006 state law protecting the right of individuals to use the bathroom or locker room corresponding to their gender identity, among other provisions. The rule applied to private and public facilities, and included stores, schools, restaurants, and most places of employment.

Major corporations like Google, Amazon, Microsoft, and Airbnb had opposed I-1515, as the Seattle Times reported.

Organizers with Just Want Privacy said they’d intended to deliver the signatures to the Washington state Secretary of State’s office Friday morning. They said in an online announcement that they will “not give up the fight.”

In a filing with the Washington Secretary of State, the petitioners argued that the state’s transgender protections would cause “potential embarrassment, shame, and psychological injury” to those sharing a bathroom or locker room with a transgender individual. They contended that the law and recent rule “interferes with a student’s right to privacy and a parent’s right to determine when their children are exposed to sensitive issues and subjects.”

Proponents of discriminatory measures targeting transgender individuals often cite such a “need for safety,” but evidence doesn’t bear that out.

“Over 200 municipalities and 18 states have nondiscrimination laws protecting transgender people’s access to facilities consistent with the gender they live every day,” a statement from a coalition policy and advocacy group recently noted. “None of those jurisdictions have seen a rise in sexual violence or other public safety issues due to nondiscrimination laws.”

As a June article in the New England Journal of Medicine noted, “It is transgender people who have generally been the victims of verbal harassment and physical assaults when trying to use public bathrooms.”

Discriminatory bathroom bills forcing individuals to use facilities that correspond to the gender on their birth certificate have been challenged multiple times in court. This includes North Carolina’s recent HB 2, which the U.S. Department of Justice has sued to block. U.S. Attorney General Loretta Lynch called the North Carolina measure “state-sponsored discrimination.”