Maternal justice for all
May 13, 2021, 3:33:04 PM
Courtesy Commonsense Birth
Spend even a few minutes with midwife Jennie Joseph and you’ll want to gather your girl posse, paint some signs and go march on Tallahassee for reproductive rights. (Not abortion rights. Though those are good to have too.) The other reproductive rights: Like the right to control your own body during pregnancy, labor and delivery. Like the right to prenatal care so you don't become one of the 50,000 women who suffer a life-threatening pregnancy complication each year in the U.S. Like the right to not be bullied or manipulated into an unnecessary Cesarean section. Like the right not to become one more American maternal mortality statistic.
“One in three women are delivered by Cesarean section at this point,” Joseph says when we meet up via Zoom. “In other words, 33 percent of babies, higher in some cases, are being delivered by surgery.”
Thirty-three percent is the national average. It’s the same in Orange County, though the C-section rate inches higher when it comes to Black women (34.6 percent) and Hispanic women (35 percent).
That’s a problem, says Joseph, her plummy British accent masking a quiet outrage. We’ve become so accustomed to routine C-sections even in low-risk pregnancies — for scheduling convenience or because the baby looks big on the ultrasound — but that’s not the standard baby exit vehicle. C-sections are major surgery — the obstetrician cuts through the abdominal muscles and into the uterus to retrieve the baby. They’re meant to be done in emergencies when it’s really touch and go for the baby or mother or both.
Cesarean overuse infuriates Joseph. “There is no earthly reason why that many women need to be delivered by Cesarean when our bodies have delivered vaginally for millennia and are designed to deliver vaginally and continue to this day in every other country to deliver vaginally.”
Because once you introduce a major surgical procedure to what should be a natural physiological process, well, that just opens the door for all kinds of complications, and none of them tend to bode well for women, but in particular Black women and other women of color, Joseph says. “They’re suffering because of this systemic approach and the condoning of this approach.”
American women experience the highest rates of maternal mortality of any developed nation — 17.4 deaths per 100,000 live births. Compare that with other wealthy, developed nations like France (8.7 per 100,000), Canada (8.6 per 100,000), The Netherlands (3 per 100,000) and Norway (1.8 per 100,000). Black women’s mortality rates are even higher — 37 deaths per 100,000 live births. In Orange County, Black women’s mortality rates are higher still — 51.7 per 100,000 live births. Black women are also more likely to give birth prematurely and deliver low birth-weight babies, the leading cause of infant mortality, according to the World Health Organization. Unsurprisingly, Black women lose their babies at twice the rate of white moms.
Research finally has a bead on why. And it has far less to do with things like poverty, poor diet and poor prenatal care than you’d think. Instead, it’s racism. The slings and arrows of discriminations and microaggressions keep the body pumping out a constant stream of stress chemicals, like cortisol, which in turn can lead to developing pregnancy complications like high blood pressure, which can lead to the very dangerous pregnancy condition known as pre-eclampsia, which can necessitate an early emergency C-section delivery.
Or everything may be fine … until the hospital delivery. Joseph points to the now-infamous 2016 case of Kira Johnson who had her second child by C-section, then hemorrhaged in recovery from a lacerated bladder for 10 hours while her husband vainly tried to get the medical staff to help her. A nurse told him his wife “wasn’t a priority.” Shocking, but sadly not unusual. Twenty-two percent of Black women in one survey reported delays and actual refusals of care when giving birth. When Johnson was finally taken to an operating room, she died on the table.
“People are dying from Cesarean sections because the same people who didn’t need one in the first place are then left in recovery to bleed out and be ignored because of color,” Joseph says. “It’s that simple. It’s that stark. It’s that plain. I’m not mincing words. It’s wrong at this point to keep mincing those words.”
Joseph draws a direct parallel to Black men being killed by police in the street to Black women dying of pregnancy-related complications in the hospital. “It’s the same assault on Black people that has always been in the United States. It is deeply entrenched in who we are. It’s not an accident in terms of maternal healthcare that we are suffering worse. But what is important is that everybody is suffering in maternal health. Otherwise, we wouldn’t have one in three women being cut [during Cesareans].
“Without being dramatic,” she continues, “these are crimes against humanity. We should have a stinking tribunal. At the end of the day, we have no excuse for this. There’s no reason to say, ‘These women are dying but we don’t know why.’ We know full well.”
BORN IN CAMBRIDGE to parents who immigrated to England from Barbados in the 1950s, Joseph was already a practicing midwife when she left England for Florida in 1989. Nearly a decade later, she founded Commonsense Childbirth, the nonprofit organization with an overarching goal to end the racial and class disparities in birth outcomes.
It's not an undertstatement to say that Joseph is on a mission. Beyond delivering babies, she’s a sought-after speaker on the topics of “materno-toxic areas,” where it’s unsafe to parent or be pregnant, and perinatal safe spots; an educator, training the next generation of midwives and support staff through her School of Midwifery — the only private school in the country run by a Black woman — and Childbirth Institute; and an outspoken activist, advocating for maternal justice as part and parcel of social justice through the National Perinatal Task Force.
It shouldn’t surprise anyone that a midwife and birth activist would do things differently at her two clinics. She has two of them: The Birth Place in Winter Garden for traditional all-natural midwife-assisted births, and the Easy Access Clinic in downtown Orlando for those who want the midwife experience but still want to deliver in a hospital.
Both practices do all the standard prenatal tests: blood pressure, urine, glucose, fetal measurements. But what makes Joseph’s practice different stretches well beyond the medical. There’s a level of support that envelops and sustains an expecting mom that’s almost like the extended family of sisters and aunties and mothers and grandmothers who would traditionally help women give birth. Joseph calls this “wraparound care.” And it seems wholly appropriate since the moms-to-be, many of whom lack their own support, seem like they're being wrapped in a great, big caring hug by Joseph and her staff.
Joseph takes all comers, regardless of ability to pay, insurance-type, or how far along in her pregnancy an expecting mom is. She and her staff meet moms where they are. They get them set up with Medicaid if they don’t have it; explain their insurance to them if they do have some (often patients are under-insured for pregnancy). They let the moms know they’re invested in their healthy baby too. And that they are not alone going through this experience.
Cherise Hinton, 33, had lost her job with the pandemic when she and her boyfriend realized ‘Uh-oh, that spotting last month was really a missed period,’ and she was pregnant with their third child. Between navigating Covid-19 hours at doctors offices for a pregnancy confirmation test and her boyfriend finding time to take off work to stay home with the kids, Hinton was well into her fourth month before she was able to get to Joseph for prenatal care.
“I have Medicaid and I’m aware that Medicaid doesn’t pay what standard insurance or out of pocket would pay. So that’s why I say they’re so accommodating,” says Hinton. “I’m not even paying what someone else is paying, and they were bending over backwards, making sure I got seen. That’s the key. It’s not just ‘Oh you’re going to get paid.’ It’s to make sure I’m safe during this time when I don’t know what’s going on with my baby, I haven’t seen my doctor and all these things. I felt like I needed special attention and accommodation and no one on staff had any issues.”
“When I do maternity, I do it through a mother-centered, midwife model," Joseph explains. "We allow people to participate in their care. We allow people to share decisions. We support informed consent. We support choice.”
When Hinton didn't want to take the fasting glucose tolerance test to check for gestational diabetes — it involves drinking a super-sweet orange soda on an empty stomach, then measuring how quickly blood sugar drops over several hours through multiple blood draws — Joseph found another method to get the same information.
"I feel like other people would have pushed and said 'Do it. This is what you have to do.' Miss Jennie was like, 'Sign this paper saying you don't want it and this is what you can do instead. 'She had me keep a log for seven days with my waking blood sugar and after my first meal. I took my blood sugar after every meal and gave her the log. I don’t mind finger-pricking myself."
Joseph's Birth Place practice testimonials page is filled with notes from women expressing their gratitude and thanks. Those who had their other children present for the delivery; who were in bed with their baby while the newborn exam was done; who felt more like family than a patient when they came for check-ups; and who were allowed to labor for as long as they needed to without being pressured into a C-section.
Like Lilipads Saint who labored for a few days with her seventh child “because his little five pound self wouldn’t come out,” she wrote on the page. “I could only imagine what they would have done with me at the hospital. The patience these women had was unbelievable.”
It’s that control over their bodies, over their pregnancies, over their birth experiences that Joseph and her team return to moms that seems to make all the difference in women's health, which in turn, naturally leads to healthier babies being born.
“Mothers are carriers, and when mothers don’t do well, that’s why you have poor infant health. We find we don’t have the same development of these high risk issues," Joseph says. "Mothers stay calm. They feel supported. They feel safe. They disclose what’s going on. They follow our directions. Some of the women were overweight. They’d had premature birth with previous pregnancies or they’d had high blood pressure or preeclampsia. They tell us, ‘Before I came here I had XYZ problem, but this pregnancy I’m fine.’
“Once a woman feels like she can say what she wants, we can go from there,” Joseph says “We’ve got to find out before we go running helter-skelter, and you’re just one number on the conveyor belt and we’ll see how you turn out on the other side. When you treat people with respect, when you maintain their dignity, when you listen, they thrive. It’s not complicated.”
Joseph’s patients are thriving. You can see it in her outcomes. Her babies are born full-term, weighing a healthy 7.5 to 8 pounds. The majority of her moms breastfeed. In a 2016 study, the rate of breastfeeding among her Black moms — 81 percent — exceeded the national rate, according to the CDC’s 2014 Breastfeeding Report Card.
Last year, her Easy Access Clinic’s C-section rate was 17 percent. That’s half the rate in Orange County and the country. It’s lower even than Advent Health Orlando’s first birth C-section rate of 23.9 percent — the only Orlando-area hospital to earn commendations in 2017 and 2018 from the Florida Department of Health and the Agency for Healthcare Administration.
Joseph's low rate is attributed partly to the fact that her practice doesn’t induce labor unless there's a medical need — a woman has to be in active labor to be admitted to the hospital. Few inductions, less need for C-sections. But, Joseph says, moms in her practice who opt for hospital births are also are less likely to be manipulated into having a C-section they don’t want. “They can protect themselves, they know what to do, they feel strong and empowered and they get their babies born,” she says.
But is Joseph's "wraparound care," trademarked as "The JJ Way,"enough? Is it enough to eliminate the effects of racism on Black women and other women of color when they go to give birth?
A small study done by Bastyr University in Kenmore, Washington, suggests that it is.
The study examined the rates of low birth weight and preterm birth among 67 women in Joseph’s practice who had a hospital birth and 134 women who received standard maternity care. (Birth before 37 weeks is considered “preterm.”)
Among women who received standard maternity care in Orange County, 15.5 percent delivered their babies prematurely while only 4.7 of Joseph’s patients delivered before 37 weeks. White women's preterm births dropped 65 percent in Joseph's practice compared to those in Orange County.
Pull out the data just for Black moms though, and the results are eye-popping: more than 21 percent of Black moms in Orange County— about one in five — delivered early. In Joseph’s group: not a single Black expectant mom delivered prematurely. Zero percent preterm births. Every expectant Black mom carried her baby to 39 weeks. Results were similar among expectant Hispanic women: every one of them carried their baby to 39 weeks in Joseph’s practice. But among those receiving standard care in Orange County, nearly 15 percent had a preterm birth.
Using The JJ Way, women of color carried their babies for nearly two additional weeks. That’s huge. That allowed their babies’ lungs to fully develop. Babies gained more weight and put on extra fat to keep them warm after birth. And they typically weighed a chunky 7.5 to 8 pounds when they were born, Joseph says. In fact, not a single woman of color delivered a baby considered low weight (5.5 pounds/2,500 grams or less). Among those in the standard care group, 15 percent of Black women and 8 percent of Hispanic women delivered low birth-weight babies.
“This is important for the public to understand,” says Joseph, “there is more to this than just ‘Oh these women don’t eat right. If only they had a better diet, they’d be fine. If only they saw their doctor right away, they’d be fine. If only they had insurance and could afford to have a baby in the first place, they’d be fine,’” Joseph says.
“The tropes, the stereotyping, the prejudice that permeates the American medical field, particularly maternity. We have a dilemma around social class, money, insurance, racism, power, all of these dynamics around something that is really quite straightforward when done correctly.”
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