Dispatches from the field: Pioneering midwife Jennie Joseph

“Unfortunately, midwifery hasn’t been integrated into the way of birth life in the United States. But in places where it’s normal and integrated, understood, and respected, midwifery as an autonomous profession is really the best, safest, most humane way to provide support for birthing and pregnant families and parents. I believe that’s because midwifery provides support that respects and hears patients, incorporating them in plans and decision making. That’s a true person-centered, patient-centered, woman-centered model, which has always held that sacredness, no matter whether in an institution, or in the community.” – Jennie Joseph

Interview with Jennie Joseph

How did you become interested in midwifery and what led you there?

I was actually called to midwifery. It had to have been a call because there wasn’t anything on the list of career choices at school that said “midwife,” but I was adamant that that’s what I wanted to do. I was in England at the time — I was born and raised there — and there were programs where you could train as a midwife. You had to be 20 years old but I was let in at 19 because I aggravated the people running the training programs so much! I was in one of the first cohorts of midwives trained in the United Kingdom who were not nurses. That was 1979 and I’ve been doing this work ever since.

Why is midwifery so beneficial?

Unfortunately, midwifery hasn’t been integrated into the way of birth life in the United States. But in places where it’s normal and integrated, understood, and respected, midwifery as an autonomous profession is really the best, safest, most humane way to provide support for birthing and pregnant families and parents. I believe that’s because midwifery provides support that respects and hears patients, incorporating them in plans and decision making. That’s a true person-centered, patient-centered, woman-centered model, which has always held that sacredness, no matter whether in an institution, or in the community.

There’s something about bringing life that has us all, as human beings, respond in a way that is nurturing and supportive. And midwifery is the perfect profession to provide that nurturing and support. Around the rest of the world, midwives support and serve women in their childbearing years. The scope of midwifery is that we are literally the guardians of normal birth, normal processes, normal pregnancies, postpartum, and even help between babies. Once something goes beyond the normal, then the midwife will refer and collaborate with a higher-level profession, typically an OB-GYN, or whatever specialist is needed. Midwives are very clear about their scope. There’s no mish-mashing of responsibilities as in, “We can do these extra fancy things.” No, we can’t. We know where the lines are drawn.

Why hasn’t the US embraced midwifery?

It is really a historical situation. In the early years of America, the community took care of births. During enslavement, African midwives delivered Black and white babies — for the slave owner, as well as for the community. In the late 19th century, Dr. William Shippen Jr., a male midwife, started teaching obstetrics and midwifery to physicians in Philadelphia. Within the field of obstetrics there was a sense of “Oh, there’s a discipline here and we should use our power and commandeer this.” And so medical practices began to grow and women were told, “Come out of the home and into the healthcare institution to give birth.” There was territorialism around who got to have the commodity: in this case, the patient.

During the early 20th century, there was a purposeful plan to eradicate traditional midwifery. Amid a lot of propaganda and disinformation about midwifery, federal laws were changed and money was applied to send public health nurses, particularly into the south, to eradicate the Black and native midwives. These midwives were told, “You’re doing it wrong. You’re dirty, illiterate, and unsafe. We are the ones who can help with the infant and maternal mortality problem.”

We now have a country where people strongly believe that without the interventions of OB/GYN physicians and hospitals, we may not make it. There is a dichotomy stemming from the belief that our maternal mortality rates are so horrendous that we must need more obstetrical care, without acknowledging that these statistics don’t just show up out of the blue. Maternal mortality and morbidity are a direct result of the broken system that we perpetuate because it serves certain interests. It keeps the power where it is, with the idea that physicians offer something that will help you more than anyone or anything else can. And it keeps the midwives out, because there’s no room for that kind of competition.

What keeps midwives out of the system in the US?

The midwife is perceived to be extra risky, not as educated, and not as capable. So in hospital environments where midwives work, they are somewhat relegated to the handmaiden position, or the support role. There’s not a spirit of collaboration nor do other healthcare professionals make it easy or safe for them to practice. We haven’t got any sense of, “We want to integrate midwifery.” It’s quite the opposite. And we have a public that accepts that. So when people do choose midwifery, they’re asked, “What’s wrong with you? Why are you doing that? Don’t you care about your baby? Don’t you have enough money?” These are the tropes and the ways that we shame and blame midwifery.

What needs to change to make midwifery more accepted?

We have a long way to go but I think we’re on the right track as people now understand that there are alternatives to what has been sold as the only way. The interest in doulas helps midwifery, interestingly, even though doulas and midwives are not the same. Doulas might not provide clinical support, but they give that emotional support, that listening ear, and help with managing pain — all things midwives do. But because of the barriers to practice and lack of integration for midwives, doulas have taken on that space, which is great, but it’s still not midwifery. Today, when midwives are employed in hospitals, they’re typically handling the low-income patients and the walk-ins. Hospital practices are saying to them, “We’re not that keen on trying to provide expensive services to them. You’re cheaper. Can you care for them?”

Midwifery practices in the community don’t often have hospital privileges in the same way that physicians do. And that’s a barrier to being able to continue their care with patients. A midwife may have a patient who plans to deliver at the hospital, and they will get delivered by the physician on call because the midwife is not privileged to come and deliver and continue their care through the intrapartum. The midwife would have to wait until a mother delivers and is discharged from the hospital, and then could resume care on the postpartum end.

An important goal would be to break that system down and incorporate a strong collaborative arrangement so any community midwife can transfer patients for complications or transfer patients because the patient wants to be in the hospital, and not be treated in the ways we currently are. Physicians would be able to recognize that midwifery is not that scary and that it works. It’s sad that so many physicians, young juniors coming into the profession, have no idea that it works because that’s not what they’re taught. They are inheriting this centuries-old fear.

There are other systemic barriers that prevent the scaling of midwifery. In particular — too few midwifery training programs, and insufficient access points for diverse midwives or midwives who might be serving marginalized communities, low-income communities, and communities of color.

How can we create a more diverse midwifery workforce?

Over 90% of midwives are white, and only 6% of midwives are Black, African American, or of African descent. This presents a dilemma because data shows that culturally-congruent care makes a difference. It leads to safer and better outcomes. But we haven’t acknowledged that, as long as there is a dearth of providers of color and providers to support marginalized people, outcomes will not improve. Likewise, we know that a majority of the disparities in birth outcomes result from Black bias. While we’re waiting to build and diversify the workforce, we should do a little extra work to have the current workforce understand this bias problem.

On increasing training opportunities, the historically Black colleges and universities don’t teach midwifery. That’s something we’re working to try to get in place. And predominantly white institutions that teach midwives have only a smattering of midwifery students of color. I have the only Black-owned, nationally accredited midwifery school in the US. So clearly it’s imperative that we identify more opportunities for folks of color to gain midwifery credentials.

But the other reality to consider is that even once you become a midwife, it’s hard to sustain a practice. If you rely on Medicaid as your payment, you will earn a third of the money that you would earn if you had a commercially-insured patient. You want to get marginalized folk cared for by providers to whom they can relate, but if those midwives can’t afford to practice, you are not achieving that goal. You end up with the folks who do get credentialed eventually leaving the field as they cannot sustain it over time and need to do something else to feed their families. This is why in my school, the Commonsense Childbirth Institute, we realize we can’t just teach students midwifery skills and competencies, but also have to consider how best to support the students in their future careers.

We teach this whole business model, about survival, and entrepreneurship — skills not typically taught in midwifery school. And our students feel empowered when they graduate. We also keep close connections with the students and the junior midwives, until they can become established in the field. We’ve learned that it’s the actual putting together of both pieces — teaching students how to center mother, baby, and the family, but also how to center themselves in the process — that allows us to grow and strengthen a more diverse workforce.

Speak about burnout in the midwifery and maternal and infant health world.

In addition to getting the workforce training and support in place, there’s also a need for what we call collective care for this workforce. There isn’t a birth worker or perinatal health worker in the United States who will not have a story for you about burnout. As part of this collective care effort, we created the National Perinatal Task Force. And we use the terminology “perinatal” rather than “midwifery” because many of the folk on the ground are using midwifery models, whether or not they’re actually clinically or physically delivering anybody’s baby. The doulas, the childbirth educators, the lactation supporters, the postpartum behavioral folk, everybody who’s in a perinatal field in a community space is more or less a midwife as far as I’m concerned.

For many, the depth of burnout is traumatizing because it emanates from the historical legacies of what happened to get us here. So burnout is on a higher level than just, “I’m tired because I just did three births in a row,” burnout. There as is the moral injury, the human side of feeling that, “Something’s wrong here but this is the only way to get through it and out the other end.” And then getting out at the other end to realize, “What have I done? My life, my student loans, my family, everything is tied up in this dream that I had, that I wanted to do some kind of medical service, but we have such a broken system and vicious cycle in maternity care in the United States that doesn’t truly serve people.”

You can reduce maternal mortality; you can prevent these deaths — if you have the will. Burnout has so many layers. And when we’re talking about folks of color, folks from marginalized groups, who are trying to come into the professions from a perspective of, “I can make it better. I don’t want to see what happened to my mother, my sister, my neighbor, happen continually. I want to break this cycle,” the burden is just tremendous.

Is maternal health siloed from other aspects of healthcare?

First of all, we’ve “invisible-ized” women and maternal health. It’s all about the baby. We build big, fancy NICUs, and then we fill them with Black and brown babies. And we’re all about the postpartum for the baby. The baby gets the pediatrician and that’s a whole discipline right there but the mother gets a six-week postpartum visit, if she’s lucky. We just had quite a bit of movement over the past year about expanding Medicaid to cover postpartum care, but, realistically, when you’ve got a postpartum mother who goes past her six-week visit and she needs care, there’s not a provider in this country who’s going to take Medicaid to provide it.

We’ve got this kind of ability to create for ourselves what I call the medical industrial complex. We want to call obstetrics a specialty, but we don’t want to specialize in the specialty. We tolerate you through the pregnancy, and then we want to get our hand on the head when the baby’s being born. Why? Because we set up insurance to say, “Once the head is out, you can bill for the entire OB episode.” These are the sort of perverse incentives that maintain the siloed approach. Whoever gets the hand on the head gets to bill for the whole thing. As a midwife, I lose a lot of money over the course of taking care of pregnant people because if I’m not actually delivering, I have to fight to get my share of that insurance money. And I don’t always win. So we do have these ways that we keep this silo in place.

In Europe or any country using obstetricians for complications, the obstetrician would be mortified if you said, “Please come here and stand at the foot of this bed. This woman is having a boring, normal birth. Could you just stand there in case?” A highly-skilled surgeon is ready to handle the complications. The midwives are there to handle the normal births. But we have siloed obstetrics in the US and created this system that serves obstetricians. The volume of deliveries is, of course, guaranteed as women in the childbearing years are going to keep having babies. You can essentially count on maybe two or three per family and that’s not too bad, when you want to be sure that your business is going to be sustained. But midwives have the complete opposite situation. I don’t think we will ever get to participate in the volume and plethora of births that are happening. This siloing is on purpose and it keeps us apart. It keeps midwives out — which is why it’s important to concentrate on creating collaborative agreements. If we could reach that alone, think about the difference it would make. That’s how we’re going to create real change.