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In our last episode, we return stateside to see how the Minneapolis-based Roots Community Birth Center is reimagining maternal care by prioritizing strong relationships and culturally centered care. We also learn about how midwives were once the go-to providers in American maternal care, but eventually became obsolete when doctors entered the picture. So what can we do to bring them back? And what would it take to open up a Roots in every state?

Learn more about the Roots Community Birth Center here: https://www.rootsbirthcenter.com/

Read about the Commonwealth Fund’s research on community-based maternal care models here: https://www.commonwealthfund.org/publications/issue-briefs/2021/mar/community-models-improve-maternal-outcomes-equity

Uncared For is presented by the Commonwealth Fund, a nonprofit foundation making grants to promote an equitable, high-performing health care system. Learn more at CommonwealthFund.org.

SuChin Pak is our host. Muna Danish is our supervising producer. Giulia Hjort is our producer and Rachel Lightner is our producer and audio engineer. Isaura Aceves is our associate producer. Mix help from Kristin Mueller. Music is by Andrea Kristinsdottir. Jackie Danziger is our VP of Narrative Content. Our story consultant is Kaya Henderson. Fact-checking by Naomi Barr. Executive producers are Jessica Cordova Kramer and Stephanie Wittels Wachs.

Follow SuChin on Twitter and Instagram at @suchinpak. Stay up to date with us on Twitter, Facebook and Instagram at @LemonadaMedia.

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To follow along with a transcript, go to www.lemonadamedia.com/show/ shortly after the air date.

Transcript

SPEAKERS

SuChin Pak, Rebecca Polston, Maimunah Memon, Alicia Bonaparte, Rachel Hardeman, Mimi Niles

Maimunah Memon  00:02

I wanted like the most intimate, natural, private kind of birth. You know, I was like, I want to feel powerful like I want to feel like I’m a part of what is going on with me.

SuChin Pak  00:17

That’s my Maimunah Memon, a nurse and mom of two who’s 37 weeks pregnant with her third son. We met her at the roots community Birth Center in Minneapolis, where she’s given birth twice before.

Maimunah Memon  00:30

I didn’t want to deliver in a hospital. I knew that there were a lot of disparities surrounding women of color. And I wanted to kind of have some say, you know, feel like I was going to be part of a team that encouraged or supported my needs.

SuChin Pak  00:49

So a couple years ago, when Maimunah was pregnant with her first child, she reached out to roots and she was totally floored by the care she received from the midwives on staff.

Maimunah Memon  01:01

We had like these really lovely conversations about what my desires and goals were for myself, it was just like, What do you want me like, share with us what your thoughts are, how do you want to birth this baby like? It felt amazing and it felt like it was where I needed to be.

SuChin Pak  01:19

Maimunah birth plan was to have an unmedicated water birth at roots, which one is planned until her baby got stuck in her pelvis.

Maimunah Memon  01:29

And his heart rate dropped from 140 to 90 within five minutes. And they were like Rooney, we’re going to need you to get out of the tub. We’re going to need to move.

SuChin Pak  01:40

After 25 and a half hours of laboring in the tub. Maimunah had to switch it up for her and her baby’s wellbeing.

Maimunah Memon  01:48

I walked out of the tub mid contraction, like holding my baby with my hand, wobbling the bed while my husband and I awesome midwives followed me. They got on the bed and they did perineal massaging and they supported me and the baby and he came out successfully and he was fine. No distress immediately started crying. After like that experience, one of the midwives was like, if you were in a hospital, they would have pushed for an emergency C section. And like I’ve heard those stories. That’s not what I wanted for myself. I was like, Oh my gosh, I’m so glad I was here.

SuChin Pak  02:29

At roots, Maimunah felt empowered.

Maimunah Memon  02:34

I wasn’t freaking out that’s the thing like in that moment when they said Mooney you gotta get out. We’re gonna get baby. Oh, I was like, okay, let’s do it. Like it. I never felt scared. I remember just feeling very calm and excited to meet my baby. And I was like, very happy to know that I had the team that I did. Now they bring that level of just peace and calmness to you. I felt like a badass just to Goddess like a divine feminine God I was like, hear me roar. Look at what I just did. Like, I just had a baby.

SuChin Pak  03:16

So how can we make sure everyone feels like a badass divine goddess during their pregnancy and labor? That safety, autonomy and support that my Maimunah, how do we make it the norm rather than the exception? Today, in our last episode, we return home to the US we will take a closer look at how birth centers like roots are making this a reality for so many people by reimagining our maternal care. This is UNCARED FOR. I’m your host SuChin Pak.

Rebecca Polston  04:01

So on the first floor is where our clinic is located. We’ve got two clinic rooms, warm and welcoming reception room with lots of pictures. We only hang pictures of people who’ve had their babies with us. We use no stock photography; I think it’s really important that people are able to genuinely see themselves.

SuChin Pak  04:22

This is Rebecca Polston, a mom of three midwife and the founder and owner of the roots community Birth Center in Minneapolis. Here she’s giving us a virtual tour of the grounds.

Rebecca Polston  04:35

And then we have a cute courtyard that’s framed by flowers and vines and plants, that’s outback and that adjoins our yoga studio.

SuChin Pak  04:45

Upstairs is where the births happen in one of two birth suites.

Rebecca Polston  04:51

I’m sitting on one right now. And both rooms accommodate waterbirth and have large comfortable beds and fluffy pillows, ambient lighting and each room also has birth balls and peanut balls and other things for comfort, we want people to move, we’ve spent very little time in the beds up here.

SuChin Pak  05:12

But Rebecca and the roots crew don’t stop at a pregnant person’s every want and need. They’ve got families covered too.

Rebecca Polston  05:20

We have a big kitchen where people can cook. And we’d have grandma making food, and just kids running around. And you can have as many people as you want here. So we want this to really feel like a place that you can make your own.

SuChin Pak  05:35

Hearing, Rebecca talks about roots, it sounds like a friend’s house or cozy neighborhood community center, not your typical birth environment. And Rebecca says that was kind of the goal.

Rebecca Polston  05:46

I knew really early on that I was really committed to stepping outside of these racist systems. Outside of these oppressive systems and putting birth back in community and having birth in community,

SuChin Pak  05:58

community and equity. These two things have always been Rebecca’s guiding light, before getting involved in maternal care. She was a community organizer in the city’s north side, which is predominantly Back.

Rebecca Polston  06:13

And as I’m doing that, and reading more about my community’s experience of pregnancy, and birth and health and systemic racism, the answers that just kept coming up where you’re dying, you’re having bad outcomes. And if you just go to the hospital more, if you just go to the doctor more, you’ll have a different outcome. And for me, that didn’t make any sense. Because how can increase contact with a racist system yield a different result.

SuChin Pak  06:41

Like we’ve heard a number of times throughout this series, we as a country have a lot of work to do to undo the racism in medicine we still see today on a smaller scale. Rebecca’s already addressing this by opening up roots in the same neighborhood where she wants advocated for housing justice.

Rebecca Polston  06:59

We are a freestanding birth center, which means that people come here for all their prenatal care, and to have their baby in our building and not at a hospital.

SuChin Pak  07:08

Birth centers like Roots are alternatives to hospitals, where care is provided by midwives, not obese. But like routes. Some birth centers have partnerships with nearby hospitals in case transfers of care are needed. While there are just about 400 births centers across the country, less than 5% of them are led by people of color, and roots is one of them.

Rebecca Polston  07:33

We do labs, we offer people, ultrasounds, we have a risk assessment, we want people to be healthy, and we help them achieve that. But where changes is how we do those things. We see instead of the way mainstream healthcare sees blackness, which is as a liability as what’s wrong with you. That’s one of your risk factors, quote, unquote. So we see that as part of the assets that you are bringing when you walk through our door, we believe that every person who walks through our door wants the best for their own bodies for their own baby. And our job is to be a steward for that process.

SuChin Pak  08:13

What Rebecca is talking about here is culturally centered care. And that attention to a person’s traditions and backgrounds has a significant impact on the clients at Roots. But how exactly does roots incorporate culturally centered care? Well, it was kind of hard for Abeka to put it into words,

Rebecca Polston  08:32

like how do you ask a fish to describe the water in which they swim. It’s just how we do it.

SuChin Pak  08:39

And a big part of it comes down to building trust from day one, the minimum appointment length that routes is half an hour. But most of the time, Rebecca stays chatting with clients a lot longer to really get to know them.

Rebecca Polston  08:54

We start with their own story. We see someone’s culture, their family, or their lack of family. Sometimes people don’t have extended family. And it’s because of trauma, we see those like wow, that’s another deeper way that we get to care for them is to care for their trauma as well. And so I just started from that framework, and also taking a look at all of these moments of how we provide care, and why we say and do the things we do and putting them through a filter of anti-racism.

SuChin Pak  09:25

And this is really making an impact with a diverse clientele at Roots.

Rebecca Polston  09:30

We also serve in addition to African American folks, a lot of indigenous folks, Southeast Asian folks, African born folks, and a lot of queer folks, because the magic is once you take a framework that says that oppression and racism isn’t good. It works for everybody. Everyone finds a home there and everyone finds respect.

SuChin Pak  09:54

Nobody knows this better than Dr. Rachel Hartman, the health equity researcher we met in episode one.

Rachel Hardeman  10:02

It’s unique in that it provides a culturally centered model of care where their goal is really to honor the lived experience of the community members that they’re serving.

SuChin Pak  10:12

Since 2016, Rachel and Rebecca had been researching the effectiveness of a birth model like Roots. In the first four years after it opened in 2015, Roots helped nearly 300 people give birth, and in that time, none experienced preterm births. In 2020, almost every client of theirs was successfully breastfeeding at six months. And that’s pretty remarkable considering that the national average is closer to half of that. throughout the US, the data shows that birth centers reduce the number of interventions and improve outcomes, especially among black parents. Plus, they tend to cost less than hospital births. At a birth center, you’re looking at an average price tag of a little over $1,000. At a hospital, that average bill jumps up to more than $13,000 for a vaginal birth. But it’s not just the numbers that back this approach. Like we heard from Maimunah’s story earlier, the client experiences at roots speak for themselves.

Rachel Hardeman  11:21

As they were telling us sort of why they picked roots, they would often compare their previous pregnancy where they may have birth in a hospital setting and shared these I mean, some of them are just horrifying stories. I mean, everything from just constantly not being heard not being respected requests being sort of brushed off. We also heard a lot of stories from birthing people who went to hospital or a clinical setting for care. And were given a talk screen for no reason, there was nothing that indicate that there was substance use or substance abuse, but because they were presenting as a black woman and that space, assumptions were made.

SuChin Pak  12:01

At roots, this sort of traumatic interaction would never happen, because according to Rebecca.

Rebecca Polston  12:08

A big component of our care is informed consent. So there’s some basic things that are required by law as a licensed facility like basic blood work, and that kind of stuff. Most of the other pieces, though, that are routine, we give people options around that.

SuChin Pak  12:25

Like, for example, giving options about whether to have an ultrasound to determine the baby’s sex, or whether to go forward with genetic screenings.

Rebecca Polston  12:35

We really explore the why behind what information we’re trying to get, and then talk about how we get that information. And we do that in partnership. And we have those conversations a month before that testing is even an option.

SuChin Pak  12:49

For Dr. Hardeman, it was groundbreaking to learn that clients at routes have so many options available to them, and how easy it is for them to have a say in their birth journey.

Rachel Hardeman  13:00

What we saw with routes is that they’ve gone above and beyond that, to really engage that birthing person in the consent process. One of the examples I always use is that typically with a clinical visit, you’re going to have to do a urine sample. Whereas that routes, what they do is say, well, here’s what we’re testing for, we’re looking for, you know, protein in your urine or glucose. And then they actually engage that birthing person and dipping the pH stick in the urine, right, and then talking to them. This is what this means this is how this works, right. And so it’s this sort of holistic model, where their autonomy is honored, their knowledge about their bodies is honored. And those discussions are had in sort of a respectful way.

SuChin Pak  13:44

Starting with ultrasounds and continuing on through birth, the roots model pushes back on the standard experience, that’s the norm in a hospital setting. And they go beyond the norm when it comes to postpartum care too.

Rachel Hardeman  13:58

Within that six week postpartum period. These families and this birthing person and their infant are getting three to six visits versus one.

SuChin Pak  14:08

Remember, the standard in the US has been one six week postpartum visit with your OB, one. And you have to travel to your provider. None of this home visit business that standard at Roots.

Rachel Hardeman  14:22

Going into someone’s home and into their environment can be incredibly powerful and important for how that care is delivered.

SuChin Pak  14:30

And one example of this always stands out to Dr Hardeman. One day of routes midwife was at a client’s home for a routine postpartum visit. When she noticed something was off.

Rachel Hardeman  14:43

The mom got up to go to the kitchen to get a glass of water and the midwife noticed she was limping. And when she came back into the living room, you know, the midwife said you know, have you always limped is this new? And she said, Well, you know, I just have some pain in my calf. And you know, after another couple Have questions they determined pretty quickly that she probably had a blood clot in her calf that was leading to a pulmonary embolism.

SuChin Pak  15:08

A pulmonary embolism typically happens when a blood clot travels up from the leg and gets stuck in the lungs blocking blood flow. If it’s not caught in time, it can be life threatening. Thankfully, she was rushed to the hospital and got the care she needed.

Rachel Hardeman  15:24

And that may not have been caught. If she had a birth at roots verse center hadn’t had a midwife in her home at that point in time.

SuChin Pak  15:36

For Rebecca, she sees this sort of attention and care as the least she can do for her clients. Her goal is for more places like routes to open up throughout the US. So pregnant people everywhere can get accessible, culturally centered care. But Rebecca knows that this type of care can be hard to replicate. Because every community comes with its own unique challenges.

Rebecca Polston  16:00

It’s not like I can give someone a playbook. I can’t say if you do this checklist, it’s now culturally centered. Because it has to be in every fiber of every moment, from those pictures on the wall, to the person at the front desk, who lives in the neighborhood and knows you, to a midwife that looks like you to recognizing that the things that happen in our communities affect our experience of pregnancy.

SuChin Pak  16:30

This holistic approach to pregnancy care is unfortunately rare in the US today. But that wasn’t always the case. In the early 20th century, community midwives were the go to care providers for pregnant people. So what changed? That’s after the break.

Mimi Niles  17:01

I have attended hundreds and hundreds of births. In into these hands, I have quote, hundreds and hundreds of human babies. And every single time it feels special, it feels like some holy sacred moment happening. So if it feels like that, for me, I can only imagine what it feels like for that parent and that family and that support system. What can we do to continually honor and protect that experience for people?

SuChin Pak  17:31

This is Dr. Mimi Niles.

Mimi Niles  17:34

I am a midwife, a proud midwife. I work in the largest municipal health care system in the nation, which is based in New York City. And I’m also a midwifery care researcher.

SuChin Pak  17:46

The big question that Dr. Niles is looking for answers to is how we can better integrate midwives into our health systems, so that they become the primary access points for every pregnant person. And the research shows just how important this is for better health outcomes. For example, in a state like Washington, where midwifery integration is ranked number one in the nation, pregnant people have much easier access to high quality midwifery care that’s covered by insurance, more integration equals lower rates of preterm births, neonatal deaths, and C sections. So why are the majority of states lagging behind?

Mimi Niles  18:29

Unfortunately, the way it is in the US is that if you choose to seek your care at home or in a freestanding birth center, for the most part, not always you have surrendered your access to the hospital. True integration of midwifery care would be I’m a midwife. I have a robust practice. And my people I take care of get to choose where they want to have their baby and I’m still going to take care of them. So they want to have a home birth, I’m going to be their midwife. They want to be in the birth center, I’m going to be their midwife, they’re going to be the hospital, I’m going to be their midwife, or they’re at home and they need to transfer to the hospital. I’m going to stay with them. So they have the continuity of my care, because continuity is a huge protective factor that is under researched and under invested in in the United States.

SuChin Pak  19:18

What Dr. Niles saying is that integrating midwives into our healthcare systems would make it easier for them to provide better care, because they wouldn’t be seen as outsiders.

Mimi Niles  19:29

So even for yourself, when you get your primary care, are you seeing somebody different each time you go in? Probably, those small sort of community physicians or community providers, we’re losing access to them too. That’s what the whole grand tradition of the midwives in the south they were the community providers before that was a thing. Everybody knew them. Not just if you were having a pregnant and having a baby, if you were sick and ill if somebody in your home was dying, if somebody was depressed, they were Calling on that elder midwife to come and teach them and guide them and support them.

SuChin Pak  20:07

To understand midwifery integration, we need to go back to the origins of the practice back to when Black enslaved women were known as the birth experts.

Alicia Bonaparte  20:17

So what you found is that these were the people who were principally responsible for helping women both black and white birth children here in the US.

SuChin Pak  20:25

That’s Dr. Alicia Bonaparte, a professor of sociology at Pitzer College in California.

Alicia Bonaparte  20:31

So not only were they responsible for helping to catch babies, they were considered healers in their communities. They were considered spiritual leaders in their communities.

SuChin Pak  20:40

And she says they’re the ones who deserve credit for helping to lay the groundwork for midwifery as we know it today. They made prenatal visits helped deliver babies and continued making home visits for up to seven weeks after birth, where they helped out with things like childcare and housekeeping. after emancipation, these midwives became known as elder granny or grand midwives. And in the early 1900s, Dr. Bonaparte says they were likely assisting around 90% of births in the southeastern US.

Alicia Bonaparte  21:15

And again, they were engaging in their practice until roughly the early beginnings of the 20th century. This is where you started to see a shift and a change in regards to who was able to practice.

SuChin Pak  21:24

Part of the reasoning behind this was a push towards medicalizing birth.

Alicia Bonaparte  21:28

Doctors in the early 20th century, were making an argument that pregnancy was something that was very pathological. In essence, they were completely eradicating the idea that pregnancy is a natural occurrence. And instead what they started to say is they said no, it is dangerous. And therefore again, it requires a medicalized birthing setting for people.

SuChin Pak  21:49

medicalized medicalizing birth led to a rise in doctors, specifically white male obese, who carved out more space for themselves in the birthing process by doing what they could to push out midwives almost entirely, especially grant midwives. And they found plenty of insidious ways to do that. One of them was public health messaging.

Alicia Bonaparte  22:12

Public health officials and doctors would send a messaging of a sort right advertisements, they would draw these horrible caricatures of midwives and say they’re horrible, don’t use them. They’re linking to all different types of diseases and death. And instead, what they say is a safer place for you to birth is actually within a hospital setting.

SuChin Pak  22:30

This messaging did two things, it changed the social perception of midwives. And it scared the hell out of birthing people at a time when infant and maternal mortality rates were high.

Alicia Bonaparte  22:43

So they were trying to figure out who do we blame, they started to blame Black ran midwives are weighing midwives. Even though the number of midwives went down as they were working to get rid of them, the rates of maternal mortality and infant mortality continued to rise and tells you something. One of the things that a number of other people found out is that doctors were not being very hygienic. And they are the reason why people were dying is because they weren’t cleaning their hands going between patient to patient to patient. So if you’re asking the question of who’s really contributing to the deaths of these mothers and their children, it wasn’t black midwives, it was actually doctors.

SuChin Pak  23:17

Remember that as this interventionist approach was becoming more and more popular, equipment sterilization was still underdeveloped. So those four steps that doctors use to help women birth their babies, chances are they weren’t properly sanitized. And that led to bacterial infections, which became the leading cause of maternal mortality at the time.

Alicia Bonaparte  23:39

But in order to cover that up, you have to scapegoat, right?

SuChin Pak  23:44

So another strategy doctors used to seize control of maternal care was by playing up the idea of White womanhood.

Alicia Bonaparte  23:53

So this is this idea of this understanding that particularly white middle class and upper class women were told you’re not meant to bear pain. And therefore you should be using different types of anesthesia efforts as a way to kind of save you from having to suffer the vagaries, quote, unquote, associated with birthing a child.

SuChin Pak  24:10

White women’s so called Saving Grace came in the form of a cocktail of morphine and scopolamine. We now know this as Twilight sleep, or an induced loss of consciousness that helps manage the pains of childbirth.

Alicia Bonaparte  24:24

And so when we think about the fact that intervention becomes an accepted thing, doctors again started to say, well, we have all this new medical training that shows your intervention is saving these women from pain. And this is what many White medical men of the time did. They said, I want to show you that I’m your hero in this horrible labor process. I’m the one that’s going to save you. And so if I can save you, you don’t need these grainy midwives anymore. You can just come to me.

SuChin Pak  24:51

Like Dr. Bonaparte mentioned, these obese can’t be characterized as heroes by any stretch of the imagination. But as the numbers of preventable maternal deaths rose, medical regulations started to shift in their favor, and so did the limits on the role of midwives.

Alicia Bonaparte  25:09

And so they started to say, well, let’s start creating practice laws, saying only you can practice if you have this formal education. If you have these licenses, if you have these types of certificates. And if you don’t have those things, then we’re going to revoke those things.

SuChin Pak  25:24

state by state restrictions popped up that limited and penalize the practice of midwifery. These regulations and this shift in mentality about birth and the role of midwives in it worked so well that the rate of home births fell from nearly 100% in 1900, to only 44% by 1940. By the 1950s, grand midwives across the country became almost entirely obsolete.

Alicia Bonaparte  25:54

The sanction efforts, not only quote unquote, were effective. But in addition to that, there was also fear mongering, that was another important tool in regards to why people decided I’m not going to practice this anymore.

SuChin Pak  26:06

persecuted and fearing jail time, it makes sense that grand midwives left the profession, they were forced out by fear tactics. And to this day, many people still have stigmas associated with midwives, that they’re not as competent as OBs, or that their way of birthing leads to worse outcomes. When the data shows us that exactly the opposite is true.

Alicia Bonaparte  26:30

What is really saddening to me is that we’re literally using these tropes that were applied to these women a century ago to talking about them now. And again, it’s this preference for I’ll have a safer birth if it happens within a hospital. So I think it’s important to talk about not only just the impacts then, but I also think what is the lasting impact of that today?

SuChin Pak  26:51

Well, history has shown us that black midwives were once known as the birth experts, the midwifery workforce is now overwhelmingly white. And this is a direct result of a history of exclusion and racism in health care. More on how we can integrate the original birth experts after the break.

Mimi Niles  27:24

When medical care was rising in the US, it was rising as a business model. It was not rising as a public service model.

SuChin Pak  27:32

That’s Dr. Mimi Niles again.

Mimi Niles  27:35

And so a lot of states have very archaic laws and regulatory environments that limit the practice of midwifery.

SuChin Pak  27:44

These type of laws known as scope of practice, laws, require nurse midwives in many states to be supervised by a physician.

Mimi Niles  27:53

In New York State, a midwife could not own and operate a birth center. We were regulated out of that space, not until 2016. Did we reclaim the right to be able to own and operate birth centers, that is our domain. That’s our expertise. And we were not allowed to do that in New York. So that just shows you how deeply sort of pervasive the roots of the system are rotted and they’re old and they’re archaic. And they were built to exclude people from access to the system, not just as patients but as providers.

SuChin Pak  28:32

Back in 2016, when midwives working in New York reclaim the right to own and operate birth centers, the licensing requirements were so demanding that zero centers ended up opening. But last year, a new bill passed in New York, that’s meant to make it easier for midwives to open birth centers. And this need is very real, in a state with no birth centers run by midwives, and where black people are five times more likely to die of pregnancy related causes than their white counterparts. But the lack of midwifery led birth centers isn’t just a New York problem. Our system has way more OBs than midwives. And that’s another reason why OBs are the go to providers for maternal care.

Mimi Niles  29:18

The obstetrical approach, which is the dominant approach in the US, is the provider is centered in the approach, right. And so it’s very risk oriented. It’s very technology oriented. The system is really designed to be highly efficient, and highly functional. And the way to do that is to treat everyone the same. It’s like going to the DMV, you bring the same things to the DMV, and then you get what the DMV is going to give you. And I think that’s how institutional healthcare works. The goal is to make it efficient because it is a business. It’s built on a capitalist business model. So everything has to run in a certain way. Everything has to run on a certain timeline, and in that model, it’s how can you send her an individual.

SuChin Pak  30:06

Like we learned from Dr. Bonaparte, this push for a maternal care model that centers obese and medicalized birth started almost a century ago. And over time, it’s only gained traction because of who’s been left in charge. Here she is, again.

Alicia Bonaparte  30:23

midwives even today make a clear argument, right of this is you birthing your child into the world, I am simply a guide. When you flip that and you think about medicalization of birth, I’m not the guide. I’m the driver. And so when we think about how the medical industrial complex kind of pushes forward this idea and this understanding of that, you come to me, because I’m the one that’s driving the situation, I’m the one that’s driving the car of your birth. This is where we see this direct contrast.

SuChin Pak  30:51

This contrast between how midwives and OBs approach birth is maybe made most evident by the fact that obese are trained surgeons.

Mimi Niles  31:02

And what we’ve done in the United States is we’ve made surgeons in charge of something that isn’t normal physiologic process for about 80 to 85% of people. But if you put a surgeon in charge, that’s the approach that they’re going to take as a surgical approach. And that’s why we see the kind of cesarean rates that we have in the United States.

SuChin Pak  31:25

While C sections can be a lifesaving procedure for complicated births, they’re not so common elsewhere. For example, in the Netherlands, where midwives run the show, about 15% of deliveries end up in C-sections in the US. Well, it’s double that. But why are we so inclined to offer C-sections?

Mimi Niles  31:47

If a physician is worried about being sued, because there might be a baby with an issue, they’re going to do C-section, because there’s the fear of litigation, that should not be hanging over the head of someone who’s trying to provide health care for someone. And that’s the other part of the system. That is a failure to everybody.

SuChin Pak  32:06

On top of that, a recent study shows an association between a hospital’s profits and its likelihood of C sections, meaning financial incentives may play a role in our high number of C section deliveries. Okay, so two of the top reasons why we’re failing at fully integrating midwives into health care are tied to money. One, we’re starting off on the wrong foot with a system that values profit over people. Two, we choose to go the intervention route too often for fear of litigation. Reason number three, is, you guessed it, also about the dough.

Mimi Niles  32:48

When you don’t have federal recognition, the people you take care of their insurance may not pay you. So this insurance is a whole other quagmire of why midwifery care is limited.

SuChin Pak  33:00

Let’s say you’re a certified professional midwife, even though your midwife license is recognized in 35 states, you have no federal recognition. So right off the bat, your role in the healthcare system is limited.

Mimi Niles  33:13

You might also have regulations where midwives are reimbursed 85% of what a physician is reimbursed, even if they’re providing the exact same service, that disincentivizes a system from even hiring midwives. Why would you if you can make $1 with a resident, but 85 cents with a midwife.

SuChin Pak  33:32

But it’s not just hospitals that are disincentivized to integrate midwives. Here’s Dr. Bonaparte again.

Alicia Bonaparte  33:38

We can’t talk about medicine, the practice of medicine, the practice of birth without engaging the role of insurance companies as a part of the medical industrial complex. If an insurance company is saying, Well, I understand you want a birth with a midwife, this is how much it’s gonna cost or we don’t actually cover that, then it’s again pushing people to go to a hospital birth.

SuChin Pak  33:55

Remember, birthing at a birth center would cost you on average, a little over $8,000. And if you opted for a midwife assisted home birth, you’d be looking at an average cost of around 4600. But regardless of where you want to give birth, if you’re looking for help from a midwife things can get complicated without a good insurance plan that covers costs. And even then, it’s not guaranteed that you’ll find an in network midwife. This is the kind of structural barrier that midwives and birthing people are up against.

Alicia Bonaparte  34:30

So what you’re talking about here is you’re having to address a legacies old criticism of midwifery as a practice. Now what’s really sad is if we jump outside United States and we grow across the pond, midwifery is a celebrated vocation.

SuChin Pak  34:45

Exactly. Let’s put that pain point in block letters size 35.5. If we learned anything from our healthcare world tour, it’s that countries where midwifery is integrated into their healthcare systems are seeing results, and their populations are healthier for it. But in the US are stuck in the past. And nobody knows this better than Rebecca Poston of the roots community birth center.

Rebecca Polston  35:14

This is where those disparities around this type of care come from. Because we don’t get paid any more than anyone else, we get paid less, actually. And we’re doing more care. And so when we are looking at how do we influence a marketplace, we are coming up as much smaller and not as competitive.

SuChin Pak  35:40

Although routes accepts private insurance, most of their clients are Medicaid recipients.

Rebecca Polston  35:46

A big part of our accessibility is that we don’t want to have to turn anyone away for lack of ability to pay. So we will also facilitate people getting on Medicaid if they haven’t already figured that out.

SuChin Pak  35:58

The problem is, Rebecca says the reimbursement rate for those clients is really low. But that’s not the only financial roadblock, Rebecca is up against postpartum care at roots includes six visits, and the first three are done at the client’s home. But routes doesn’t get any sort of reimbursement for these.

Rebecca Polston  36:20

I want to be clear, but we don’t get paid for it. Insurance does not cover these visits. And so we eat the cost. So it is a real, it is a real issue.

SuChin Pak  36:30

And it’s gonna take a lot of pushing and prodding to fundamentally change the way we see midwives in this country. For Rebecca, it’s not easy to cover costs and stay afloat, but she does what she can in the name of community and racial health equity.

Rebecca Polston  36:47

I think that this is where we step out of the individual practice and into the larger social good of what we spend on maternity care is that we spend all this money on the wrong things. We should be spending money on things like this, there should be a roots in every community, I should not be unique.

SuChin Pak  37:08

So what needs to change for Rebecca’s vision to become a reality?

Rebecca Polston  37:12

First, we’d have to increase reimbursement for Perinatal Services, periods, that needs to happen at the Medicaid level. There’s other people out there kind of doing it, but they’re either heavily subsidized, or they are not taking as much Medicaid as the population reflects, we should not need a subsidy to provide this care, because the savings are the people don’t have as many surgeries or bad outcomes. And we need to shift so that more postpartum care is covered and ideally covered for the first year after a baby. If those things can happen from a business perspective, it works. But we definitely need those things to shift.

SuChin Pak  37:55

More than half of all pregnancy related deaths happen in the year after birth. So expanding care during this time is critical for improving health outcomes and addressing racial disparities. As it stands, all states are required to provide Medicaid coverage up to 60 days postpartum. As of November of this year, 26 states and DC extended coverage to 12 months for Rebecca and Dr. Rachel Hartman, and so many other advocates for midwife led maternal care, places like routes are the way forward.

Rachel Hardeman  38:32

I feel like as we learn more about this model of care is like, well, all of this just makes perfect sense, right? It’s just kind of like common sense. But because we have a healthcare system that requires sort of a certain level of efficiency, right that like a place like routes is not they may be less efficient. They probably will see less clients in a day. But they also are getting people what they need, and they’re feeling heard and feeling like their lived experience is being honored in ways that folks who aren’t being seen in that model, don’t get.

SuChin Pak  39:05

Yes, there are very real financial limits to maternal care models like roots. But again, the proof is in the pudding. Parents and their newborns have better outcomes at places that embrace birth as natural, not pathological. But it’s not just about seeing birth differently. It’s about rethinking our approach to health care. In Costa Rica, health care is a human right. The closest our country comes to that is the Affordable Care Act, which has provided coverage for millions of previously uninsured Americans, and expanded Medicaid eligibility under the Act has significantly slowed the rise of maternal mortality among black birthing people. But millions are still left uninsured, partly because of affordability or eligibility issues. Meanwhile, countries like Costa Rica, Germany, the Netherlands, they all Have near universal health care coverage? Unlike the US, yes, policy change takes time. And who knows if we’ll ever be able to achieve health care for all, but we can start by looking at how to improve what we already have. And that means acknowledging the historical and continued racism in healthcare. It means paying more attention to the social determinants of health that shaped the kind of life we’re able to live. Are we able to access affordable stable housing, a livable wage, education, health care? Too often? The answer is no. Even though these things should really be the most basic of rights, but there are smaller steps we can take at least for equitable maternal care. We can prioritize maternal mental health by expanding Medicaid coverage postpartum, we can improve birth outcomes by covering the cost of midwives. We can make our systems more inclusive by growing and diversifying our healthcare workforce. We can prioritize models like routes that put their community first instead of profit. We can make these reforms and many others a reality. America doesn’t have to be the outlier.

CREDITS  41:40

UNCARED FOR is a production of Lemonada Media. I’m your host SuChin Pak. Muna Danish is our supervising producer. Giulia Hjort is our producer. And Rachel Lightner is our producer and audio engineer. Isaura Aceves is our associate producer. Mix help from Kristin Mueller. Music is by Andí Kristinsdóttir, Jackie Danziger is our VP of narrative content. A story consultant is Kaya Henderson. Fact checking by Naomi Barr. Executive Producers are Jessica Cordova Kramer and Stephanie Wittels Wachs. This season of Uncared For is created in partnership with the Commonwealth Fund. There’s more UNCARED FOR with Lemonada Premium subscribers get exclusive access to bonus content, like interviews with health experts, midwives and doulas. Subscribe now in Apple podcasts, follow UNCARED FOR wherever you get your podcasts or listen ad free on Amazon music with your Prime membership.