15 Minutes With: Jennie Joseph, LM, CPM, Talks Midwifery, Maternal Health and Maternal Mortality in the U.S.

Can you explain what midwifery is and what midwives do?

Midwifery is a medical practice that also incorporates spiritual, emotional and family care during the maternity time. We take care of women during this normal life process, and if it becomes abnormal or high risk, that’s when an obstetrician steps in.

Historically, women have always helped other women during birth, so the profession of midwifery is one of the oldest professions if you think about it.

The difference for the American concept of midwifery, is that back in the day, everyone used a midwife, and everyone was born at home. Around the midcentury, hospitals and physicians decided to move into the profession, seeing it as a commodity — as in there is money to be made during childbearing. Obstetricians in other countries around the world typically are on standby for high risk cases but in the United states the widespread use of obstetricians moved midwives aside and nearly eradicated midwifery — particularly midwives in certain communities, such as Black midwives serving the southern states, Indigenous midwives and immigrant midwives.

The new idea was that you should be in this hospital situation, that everyone should be with high-level providers. So we switched from having 90% of births happening in the home environment for centuries to the institutional birthing that is now happening in the United States, always monitored by high-risk specialists. We changed childbirth into a non-normal event, a dangerous life-and-death, living-on-the-edge kind of situation that can only be solved by getting yourself into the hands of highly skilled specialists.

How does midwifery fit in with traditional OB-GYN medicine?

OB-GYN medicine that incorporates midwifery may have midwives on staff — nurse practitioners who are practicing in the midwifery model of care. And those people who do the pre- and postnatal part of care. They follow you to the hospital environment and support you in the hospital.

The other way that it’s happening is in the community space where there are midwives — like myself — who have their own freestanding clinics and birthing centers in the community where they offer low risk and healthy women the opportunity to have a natural birth. This is where a lot of the water births — for example — are happening in these types of settings and communities.

And of course there’s also quite a large contingent of folk who choose to have a natural birth at home. And by natural birth, we’re saying non-complicated, no medication typically, and you learn to manage your pain in other ways. This may be movement, water, different herbal teas, aromatherapy — all these other natural modalities to help you through the process of birth.

It’s becoming more popular to integrate a midwife like myself who has a freestanding practice. I’ve made it my business to work with a hospital should something happen during the course of the midwifery care. For example, during prenatal care if someone gets high blood pressure, they are no longer for midwifery care because they’re at high risk. So, we transfer the care to the obstetrician to manage the high-risk pregnancy.

Sometimes this happens during labor — you can’t really predict labor. So, if something happens, we transfer from the birthing center or home to the hospital to finish the birth.

When midwifery is integrated and part of a collaborative of providers, we see the safest modality you can possibly choose. You have the best of both worlds: You have that support and the medical care that midwives can offer as long as you stay low risk, and you also have the opportunity for medical care or emergency care if you become high risk.

When you integrate that type of comprehensive model, you have a model that mirrors everyone else’s model around the rest of the world because midwifery is a standard profession everywhere else.

In America, we’re at the point now where we’re at a bit of a dilemma because midwifery is not autonomous here. The general public are not even really aware of what midwifery is, and many people think midwives are doulas — but they’re not.

What is the difference between a midwife and a doula?

The difference between the midwife and doula is that the midwife provides both sides of the equation. The same support that a doula would provide, which is educational support, emotional support, listening, planning and helping you determine what you would like and what you wouldn’t like. Doulas are physically with you from the start to the finish of your labor and delivery, and they provide continuous non-medical care according to your own wishes.

They can also help you in the perinatal stage with nutritional information and during postpartum with the newborn and lactation.

Midwives provide non-medical, supportive work in the maternity world plus the medical aspects of maternity care. For example, they will check your blood pressure, check your urine, measure your tummy, see if your baby’s heart rate is normal, help you prepare for the birth. They will make sure you have everything for the event. And then during the event, they can continue to provide you with medical care and monitor you, manage your labor, help you deliver the baby and help with recovery.

So, the medical aspects of maternity are provided by the midwife, the emotional and support aspects are provided by the midwife or doula, and the high-risk aspects such as complications — high blood pressure, preeclampsia, prematurity, babies with abnormalities, mothers with postpartum mental health conditions — all of these require higher-level specialties and an obstetrician.

So you can have both a doula and a midwife?

Yes. You can have both. You can also have a doula and an obstetrician — which is what a lot of people do. In the hospital, the doctors and nurses work with the doula, and the doula continues postpartum care.

It’s a partnership, and integration is the key. If all these providers could work in harmony, the result would be the improvement — or I would say almost the eradication — of horrendous disparities that we see not only racially but socially. Low-income women, women who are uninsured, women who are on Medicaid all have different outcomes — not based on their physiology but based on social construct that impacts how people treat them.

So, whether it’s race, class, immigration — whatever the status that has that person “othered” — we’ve seen a continual set of statistics that report that their care is different compared to everyone else. And these differences in care are where these disparities come from. That’s why we are so woefully behind every other developed country in the world. We are the most highly resourced country ever, and yet we have mothers and birthing people suffering structural harms and ways of being that literally impact their experience of childbearing to the point that it’s so detrimental that we are all suffering.

Read: The Cost of Racial Bias in OB-GYN Care >>

The maternal mortality rate is so high in the U.S. — particularly for Black women. What role can midwifery play in improving the rate?

This again goes back centuries. Midwives have made sure to center mother and baby, center the family, and deliver the medical care. Midwives can address this issue in the United States by essentially just being themselves.

This is why scaling midwifery, integrating midwifery and growing that profession is key. We train midwives at my school to be community providers. We get more people access to midwifery as we grow the profession of midwives, and we support the midwives as we integrate the midwives. So, it’s a very deep impact on our outcome.

For example, our practice has been up for 27 years, and we have not had a premature percentage over 5% since we’ve been working in these clinics and birthing centers. When we first started this work, 1 in 5 Black women were having a premature baby. In our practice last year, we had four preemies and all survived and all were fine. The year before, we had one preemie — and that’s out of about 400 to 500 women every year.

Read: Can Living in the U.S. Increase Your Risk of Preterm Birth? >>

The midwifery model is protective. We make sure people feel seen and heard. That they can feel partnered in their care. And it doesn’t matter if you have the baby in your back bedroom or in the hospital — when you have that care from midwifery, you’re going to have a better outcome. We have very few cesarean births. We have very few complicated births.

Not to blame anyone — it’s just the system — but the way we do obstetric care in the United States is so cold and impersonal and so rushed that there’s no room for a calm approach. Panic and fear, intervention and legislation — I call it the industry fear — we have to learn how to navigate that industry in order to be able to survive it. And there’s something wrong with that. That doesn’t make sense. So, midwifery is one answer to that.

How would someone find a reputable midwife?

We currently have almost 400 perinatal experts listed on the National Perinatal Task Force. Those experts are groups of midwives, doulas, child experts, lactation educators — people who are operating in their community to be a place where you can get good information and good support.

What are the main things you’re hoping to change or improve in the U.S. with midwifery?

If I was able to dream — if I could really just be wild with my hope — I would say that I wish every person had access to a midwife. They may not choose to use one, but at least they have access if they should choose it.

I wish everyone could have a sense of peace, a sense of joy, a sense of accomplishment for the experience of going through childbearing and bringing life. That they know they are supported. That they are loved. They know they are recognized for what they are doing and how they go forward. But we are way off of that goal.

Let’s hope, and let’s keep working. We have to work toward that. It doesn’t just happen.

What can organizations like HealthyWomen do to help with the maternal mortality rate?

This is where we know the power of advocacy — of really getting to our systems that have these perverse ways of being. Our hospital systems are overrun. They are understaffed, and the existing staff are at their wit’s end. They don’t want to cause additional harm, but they are stuck. So, we need policies where we can support community-based organizations to integrate with the hospitals to support them. As I mentioned earlier, our outcomes at my clinic are pretty stellar — no low birth weight, no premature births — we’ve never lost a mother. No one has ever died in the entire 27 years, and that’s because we work closely with our hospital.

We are bringing together the collaborations, bringing the stakeholders to the table, bringing the policies that allow us to get along as opposed to keeping these silos so far apart. It’s community organizing and advocacy education that helps solve the root cause of these disparities. It’s not that a mother had that bad outcome because she’s living with obesity. No! It’s because there’s not enough structure to give support to her.

People in the nonprofit and philanthropy world need to provide help to those who are still shut out and change the systems we already have in place. Those systems have to change. So that’s the work.