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#006: Midwives, Doulas, Maternal Healthcare—Oh My! - Part II
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In part two of Midwives, Doulas, Maternal Healthcare—Oh My!, Michealle Gady continues her conversation with Molly Firth and Suzanne Wertman on the urgent need for change in maternal care. They explore the impact of systemic racism, provider burnout, and gaps in mental healthcare, emphasizing why a shift in care delivery is essential. Through personal stories and professional insights, they highlight key solutions to improve maternal health outcomes.
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Welcome to the Adometer Sway podcast, with meaningful discussions on the challenges of healthcare and the solutions behind them. I'm your host, Liz Church. Each episode, we dive into the complexities of our health and social system, gaining the experiences and insights of the guests that shape our lives and our communities. This is episode part two of Midwives Doolets Maternal Care O Mai, where I have the pleasure of speaking with Molly Furrick and Susan Wartman. In part one, our guests taught us about midwifery, the praise for dual lips, and expressed the need to change in care delivery. Systematic racism and bias, lack of mental health care, as well as provider burnout, all impact on how maternal health care is given. A little recap for you all, I'm going to playback just a bit from the end of part one, picking off where Suzanne's breaking down the decision making in the health system level, and how nurse midwives and other advanced practice providers who are not physicians do not have voting privileges to make decisions at the institutional level.
SPEAKER_03But, you know, because organized medicine is in charge and has so much control over the market, we we have these inequities in rates. So it then creates this disincentive for practices like why would you hire a midwife when you can get a better payment from a physician, higher payment from a physician? It's like you get you're getting taxed for hiring midwives and using midwives in your facility. And then finally, decision making at the hospital and health system level. It happens through the medical staff. And for nurse midwives and other advanced practice providers who are not physicians, we often are not able to or not allowed to have full voting privileges. And that would be helpful for us to have those able to make decisions at the at the institutional level. So in the Department of Obstetrics, you know, being able to say, you know, no, we're not gonna, you know, use this induction policy. We're gonna do this, this, and this because we know this, this, and this supports physiologic birth, but we don't have those voting rights. So, you know, oftentimes midwifery practices grow in a community. And then what we see is that they are the first to be to be jettisoned when when a facility is looking at their bottom line, when they're looking at like how how are the numbers looking? Well, we can't support the you know midwifery practice anymore because we're just not making enough money. And the midwives have no deciding power in that. It's all decided by the the medical staff, which is which is physicians in most cases. And I'll give you a perfect example of the of the the privileging thing right here in at New Hanover Regional Medical Center, you know, we there was a a rule that the OB department came up with that a physician had to be in-house from the same practice of a midwife if a midwife was attending a person in labor. Now, why would you have two people in the same place for one person's job? And so as a result, how that plays out is that the only practice, well, there's there's a there's another practice now, but for a long time, the only practice that had midwives was the residency program because the residents were always there 24-7. The private practices weren't there. Now one of the private practices has reintroduced midwives, but but you you have to have a big enough practice to be able to have two people in the in the hospital at the same time. They're never gonna get called, hardly ever. There is always a physician in-house because we have a residency program. So why would you make a rule like that? Liz, I love your faces.
SPEAKER_01I have the best faces, darling.
SPEAKER_03The people that are blowing were blowing your mind with this information.
SPEAKER_01I'm getting an education today. I love it. Every time I interview someone, I'm learning something new.
SPEAKER_00Goodness. So, Suzanne, I had asked you before, you know, making the episode if you could provide any success stories of progress being made in improving maternal health outcomes. Can you provide one? Maybe one. I mean, you gave me a lot, so like however many you want to go through.
SPEAKER_03I think the one that I want to talk about because people who are listening to this podcast are interested in policy changes, I'm gonna talk about New Jersey because New Jersey is doing some incredible heavy lifting in this space because of Governor Phil Murphy and his wife, First Lady Tammy Murphy. She came in during his first term, and she and her staff have decided that enough is enough. New Jersey has some of the worst rates for infant mortality and maternal mortality in the country, which might be surprising to some people because it's in the Northeast. There's a lot of urban centers where you know research is being done. It's the home of Johnson and Johnson, all these different, you know, pharmaceutical companies, they should be doing a better job, but they're not. And most of it is is is because of racism. And yeah, anyway, when do we come back for the second podcast? But um, but what they what they have implemented is just incredible in terms of supporting the proven solutions, supporting the the things that we know will work. And they're not high-tech. Surprise, surprise. They are supporting midwifery care, access to doulas, birth centers. They're gonna be opening a maternal care innovation center. I hope I got that right, in Trenton, New Jersey. And you know, they've been able to put millions of dollars of state funding into these solutions. And I think in the next 10 years, we're gonna see amazing results from these efforts. And they've been so systematic about how their approach that they came up with a playbook, and it's any state can use the playbook. It's the National Governors Association put this together, and along with Tammy Murphy's staff, and you just follow the book. There's a recipe out there. There's no reinventing the wheel. It's fantastic.
SPEAKER_04It's so nice to see a state take it on in a comprehensive way because I feel like a lot of states are nibbling around the edges and like we can do this, and then we can do this other thing. But it's nice. I don't know. I I'm all about incremental steps, but I also feel like you have to have a bigger picture plan and a strategy. And in my brain, there's a lot of that happening, but I'm not seeing that happening in the way that it's in my brain within my state. And I feel like I can only push so much from my vantage point. So I like Jersey.
SPEAKER_01I'm like, ah, like well done, well played.
SPEAKER_04Um but I also love that it was the first lady who was like, this needs to happen. And in like Washington State, the first lady was really critical in helping to get the dual reimbursement under Medicaid moving. It has been a many-year process and it is still not quite there, but it would not have been in the governor's proposed budget in 2019 if he had not pushed for it to be in there. 2018, 2019. I don't know. All the years run together at some point.
SPEAKER_03And speaking of women in politics, you know, the vice president has been a supporter and a champion of the you know black momnibus bill that's been trying, we they've been trying to move through the through Congress. And you know, the White House now has a package of recommendations for improving maternal health. And really, I think I don't understand why it's broken down by state. Like we should all be moving together uniformly to to to move the needle on this. So hopefully, with the you know, the federal influence and you know the things that are coming out from HRSA and CMS, and then those those state initiatives will see some movement.
Michealle GadyYou know, all the states, states are unique and beautiful snowflakes, and they all have to have their own, you know, variations on the theme. Instead of just doing what we know works, we've all got to just, you know, shove a little bit of our state-specific whatever into it.
SPEAKER_04Well, I also think, and I don't know if this has been your experience, Suzanne, but I feel like you kind of touched on it in talking about the like issues between OBs and midwives. There is a lot of turf in this area that is fascinating to me. It is one of the turfiest areas I have ever been engaged in, in a way that I'm not sure I fully understand. And it's hard for people to come together and talk about solutions in a way that is comprehensive, that involves all of the folks who are going to be involved. I think that that is really just a travesty. I'm I'm it makes me sad because I feel like we could do so much more if we weren't having all the infighting. It's really hard. There is no advocacy coalition that is comprehensive in Washington state that is focused on this issue. And there have been a couple things that have come close, but everything always breaks down in some way. And I think that it does take a village of people to talk from the same song sheet about an issue to be able to have that impact. And it just, I don't know, I feel like that's getting in the way. And probably we're not, I'm sure Washington State is not an isolated incident.
SPEAKER_03No, and and I mean, I pains me to hear that because you know, I Pacific Northwest is midwife nirvana in terms, and I would use nirvana very loosely, um, but it's better than any place else in the country. Uh culturally, you know, the relationships between midwives and physicians seem from my conversations I have with my colleagues who practice there, seems like it's better. Better, better, but still, you know, I am so pleased when I can work with physicians who get what I do and understand the the the value that I bring and that we're not competitors, that that it's not an either or. That said, those physicians get from their from from by their colleagues, you know. If they stand out as supporting midwifery, a lot of times their their colleagues will shun them. And it's crazy town because it's like we're not solving the pro like it's like, come on, the house is on fire, stop. We gotta we gotta work together to fix this. And yeah, it's it's fascinating to me. I think it's a lot of it is about the history of midwifery in this country, and you know, we we know the history, we know that it's been tied into slavery and abortion, and these are things that we grapple with already as a society, but we need to grapple with them and address them in a meaningful way, otherwise we're just gonna keep getting the same results.
Michealle GadyAnd I think in many ways, Molly, you really did hit the nail on the head with, you know, we've got serious access issues, we've got serious quality of care issues, we've got serious outcome issues. And really, every time I look at it, at the foundation for me is in fact this carpet squaring, these turf protection issues, whether it's between types of facilities or types of professionals or professionals in facilities, you know, it's all of these different layers. And really at the end of the day, you have people who need different levels of care in different kinds of settings with different kinds of professionals. And it shouldn't be this hard. But if everybody is trying to protect something, then we can never get to protecting the patient. So I I for me, that really is at the foundation of all of these issues.
SPEAKER_04I 100%. I think you said it very, very eloquently. It's yeah, it's messy and we can't do what we need to do. And I mean, I think we could get so much further in what we're trying to accomplish. Oh, we totally could, yes. I just I I look at, you know, I've been involved in policy and advocacy for years and like we've been so successful in so many issues because we've been able to bring everyone together and move forward. And I don't know, I feel like we get so stuck on some of these pieces that seem like they could be overcome when I'd rather us be spending our time trying to figure out, okay, but look, these patients need more support. They need support while they're laboring, they need support after they've given birth. These babies do not come with a manual, people. Like, oh my God. Like I swear when we left the hospital, I was like, are you sure? Are you sure this is a good idea? Like, I'm sure I look like Marcy's good. I feel like I almost died. I can really walk, like really, and then like lactation issues, counseling, like I needed everything, and I could only focus on feeding my baby for the first 10 weeks, let alone bonding with her. Like it was a mess. And like my doula would walk in the door and I would just start sobbing because I was so overwhelmed and I had no idea what the hell I was doing. And I just we need help. Like I had resources to be able to pay for these things out of pocket, or I had insurance to cover lactation. Like I still had to get to the lactation consultant every week for 10 weeks. Like we're on a long-term plan. Like, I mean, this stuff is hard and we need support. We need a village, and we're so focused on turfiness that we're not able to give people a village. I guess that's my like that's where I just shake my head at all of these things, and I'm like, why? Why can't we do this better?
SPEAKER_01Because, you know, we should be able to have. I mean, obviously, like this episode and people listening to it, they're gonna be educated and they're gonna understand, like, oh, there are a lot of things that we need to address here. This is not a one and done situation. You you can't you can't simplify this to a one and done because it is expensive, just like Michelle said. So this is where I I will ask everyone this kind of question like, where do you start? So, like in regards to policy changes, what do you like if you had to simple simplify it? What changes do you believe are necessary to challenge these met these issues in maternal health care? I know it's hard. I know it's hard.
SPEAKER_03I mean, I am gonna I am gonna say midwifery for every community. Because I was the my first answer would have been universal health care.
SPEAKER_01Before that.
SPEAKER_04No problem. I'm sure that's gonna happen soon. The universal healthcare. No, no, no term issues there.
Michealle GadyNone, none at all.
SPEAKER_04I honestly I think so. My one of the things that I I mean, paid family leave, obviously, would be a big help. Uh so that's my wish list at the federal level that's probably a ways off.
Michealle GadyBut no, with universal healthcare, Molly. It's over there.
SPEAKER_04I don't think it's quite as bad as university.
SPEAKER_03You don't think? Okay. But I love Molly, the idea of nibbling around the edges because yeah, it's funny that there's bipartisan support for maternal mental health. It's like, yes, mothers would not be having maternal mental health issues if they had what they needed.
unknownYeah.
SPEAKER_04Well, and on that, so what I was gonna say is, you know, I think we do not do enough on the mental health piece for new parents in general. And I think that there's a lot more that we could do around home visiting. There's a lot more that we could do around, you know, just calling and checking on new parents. There's, you know, the problem is that, you know, clinicians and I'm sure midwives, you don't get paid to like call and check on someone. And yet having somebody to from an office, I don't even care if it's the person who delivered a baby or was the closest to them, but to be able to call and check in on folks between their, you know, delivery and their first postpartum visit, between their which is six six weeks away.
SPEAKER_03Yeah.
SPEAKER_04Not not for me, but yes, six weeks.
SPEAKER_03Right, we might we might have had closer, closer follow-up.
SPEAKER_04But like six weeks, like that's six weeks of not knowing what the hell you're doing and not having anybody check on you. Like, because they're not, they're not checking on you. And even with my serious issues, like I wasn't getting any check-in calls at all. And then after that postpartum visit, wasn't getting any check-in calls. Listen, it was incumbent on me to follow up on the recommendations for a therapist from my doctor. That was all well and good. I am a capable adult. I can do that. However, I was busy trying to feed my child, and it took all of my energy, all of my time to nurse, to pump, to warm up bottles, to acquire milk from anyone that would give me breast milk, like anyone in my community. I was shameless. That was my focus, and that was where my focus had to be. So when my doctor asked at my postpartum visit six weeks out, was like, hey, have you checked in on counseling? I was like, no, I'm busy with these other things. And then it took me until I was done with lactation, had figured out, had the milk supply, could feed my baby. Took me a couple of weeks to like, you know, I don't know, enjoy that I wasn't pumping constantly and trying to acquire breast milk to actually finally be like, oh, I guess I should follow up on this before I go back to work. And I guess I should schedule it with somebody. And that was great. I am so glad I did it. But it took a while for that to happen. So, like, just having somebody check in and be like, hey, don't forget this is important. I know you have a lot going on, but just want to make sure you're not losing track of it. Like, that's really important. Like, we gotta be, we gotta give some extra support to new parents.
SPEAKER_03I just it yeah, yeah. Another point for New Jersey, they implemented, you know, everybody gets home visits. Everybody. It's not just folks with with insurance from a private payer. It's all every everybody. And and the nurse family partnership, you know, it it happens in places again. A perfect example is right here in Wilmington. Like every other city in North Carolina has nurse family partnership except for Wilmington. Why? Because we're doing okay. We don't need it.
unknownRight.
SPEAKER_03What oh, somebody would have to write the grant for that.
SPEAKER_04I think I think home visits are clutch. I I mean, I was so happy when my totally my doula would come. She brought me a scale to like help weigh the baby because I was freaking out so much. And like she's deluxe.
SPEAKER_03That's deluxe dual of service. That is not standard doula service. That is really, and you should have like there should be healthcare providers that come into the home that work in the community. But when we moved into the hospital setting, that's right, all of that away. It was there, we've had this, we've had this.
SPEAKER_04We've had it in Seattle. Like we had like home visits for everyone back in the 70s. Because I've talked to lobbyist friends who were like, Yeah, no, I got that. And it was amazing. Like, yeah, let's bring that back. Let's do that. But it's like, you know, there are so many challenges for new parents. It's hard to know where to start. But I just think whatever we can do to focus on the mental health needs, I just it can't be, it can't be undervalued the way that it is now. And I feel like it takes a lot of people to recognize when mental health situations are happening. And also we don't tell people enough about all the mental health conditions that can come up in the pregnancy or postpartum period. Like anxiety, people generally are like, I don't know what's going on with me. Like, I don't know what's happening. I'm I'm I'm not I'm not sleepy, but I'm not sad. But they don't understand that that's postpartum anxiety. And that's very normal. Like that happens. And so I just think, you know, there's so many pieces in that respect that I would like us to do better on. And I think, you know, it's separate from who's delivering babies. I think that's an important issue. I think people should have doolas. Midwifery should be more common and understood by people when they get pregnant. And let's not forget that these poor people have been through a lot and have a lot going on in the postpartum phase and need just a lot of hand holding and support. So yeah.
SPEAKER_03And that's part of the midwifery model, you know, is to have that ongoing, that ongoing relationship through the through the the immediate postpartum. And when I say immediate postpartum, I mean just, you know, the first six weeks or so. You know, the other thing that's been amazing that's happened, because we won't focus just all on the bad stuff, but you know, having Medicaid expand or extend, I like to say, extend out to 12 months the coverage in most states. It's that is really gonna make a huge difference because Medicaid covers 50, 50, nearly 50% of the births.
SPEAKER_04Yeah, and in some states, yeah. It I I worked on that in Washington State, and it was it's that was such an it was surprisingly an easy sell for a lot of folks because everybody has a mom.
unknownEverybody can have a mom.
SPEAKER_04Turns out it turns out that that is, and people have been through things, they've watched their partners go through things, they've been through things themselves, they've watched their children go through things when they've been pregnant. Like people are seeing things happen and they're like, Yeah, that is crazy town. I mean, honestly, I remember years ago being like, oh, two months postpartum, like that seems okay, fine. And then I had a baby and I was like, oh my god, two months, like you lose coverage in two months.
SPEAKER_01Two years, two years.
SPEAKER_04I don't I don't what I I can't even I can't even comprehend that. Like, and so I mean, I just I'm so glad that we've figured this out and now that is something that can happen. I I wish that states had been required to do it because I think there's still some states that are dragging their feet a little bit, but I'm also so happy to see how many states have taken up the option. So it's it's great to watch. It's amazing.
SPEAKER_03And I think you know, it gets to the the another point, you know, for me is like we need more women in in politics, we need more women in policymaking because they have had the lived experience, and we need, you know, not just white women, black women, brown women, you know, for sure. Yeah.
SPEAKER_04And yes, it's such a messy space to be involved in.
SPEAKER_00Like it is, but it's important that it's done. And like when earlier when we were talking about what New Jersey's doing and Washington, like my first thought was we just need women to rule the world because they actually get stuff done.
SPEAKER_01So I mean, I mean yes, that's the obvious answer, you guys. We're done. Podcast done. We rule the world.
SPEAKER_03Excellent.
SPEAKER_00I mean, it is excellent. So it's not 100% special. When you look at it, you're like, there's women that have the experience because they went to themselves, or they witnessed someone else go through it because somewhere. You know, Molly said, we all have we came from somewhere.
SPEAKER_01We know what needs to change.
SPEAKER_00So we have people that can say, you know, I live through it, so I know it needs to change. That's where we have to force people to be like, hey, I really need you to pay attention. You need to read this thing. We're gonna educate you today because some some stuff there's no question. Stop doing it. So I would care. We're not gonna do that to have a better quality of life. Like, there's no question, like, do they need it? Yes, they absolutely need it. We shouldn't have to actually say, do they need it? Like, yes. It's been proven it's absolutely needed. And I would end the podcast on that, but we're not going to do that. So obviously, Molly, you're in Washington State. Suzanne, you're here in North Carolina, two different sides of the country. So, for this question, this is really for the people who may be uncertain about their birthing options. What advice or steps would you offer to help them make informed choices that align with their preferences and values? Molly, you can go first.
SPEAKER_04I guess I would say I want people to understand what the options are and that there are different things, and different things are going to be better for different people. Like, I knew I wanted to be in a hospital with a NICU in case things went wrong. I didn't know that I could have a midway and be in a hospital with a NICU. Like, imagine that. Like, nobody bothers to tell you these things. So I just I want people to understand that there are all of these options and that, you know, some insurance will cover all the options, some will cover not all of them. Like most insurance doesn't cover having a doula yet. Hopefully that will come soon. But I want people to understand what the options are so that they can really evaluate what's going to be best for them. And that's in the like as soon as they get pregnant, but then that they can also change and that if they find something that doesn't work for them, like what Michelle had happen, that they can switch and that's okay. Like you want to find the right fit because this is a huge thing that you go through, right? Like giving birth is no joke. Like I know people have been doing it forever, but wow, no joke. You want somebody who you're comfortable with and you want somebody who at the end of the day, you're like, yes, like I got the care that I deserved and that I wanted to have, and I felt heard. And so making sure that you find that right fit for you is so critical and so important. And so I just yeah, understanding that and making sure that you find that situation, whatever it takes, if it's talking to you know, everyone about what who they used and interviewing different practices, I think that's important. So that's my piece of advice.
SPEAKER_03Yeah, what Molly said. I really think you know, the one thing I would add is like do read, you know, or emphasize do your research, you know, talk to other people and talk to a lot of other people. And there are so many resources. I think now, gosh, I think about, you know, my son is 18, and you know, for what was available then to what's available now for people, there's so much information online. And I think really checking, checking out, you know, what are the options in my area, it takes a little digging. It shouldn't, but it does. And and you know, talking to lots of people, I would also back up what Molly said. Knowing that you are in charge and that these people are working for you. So the doctors and the midwives and the dualists are working for you, have coming into the experience with that, I think that helps you be a better consumer of healthcare. It's hard because it's uh it's it's purposely set up for a power differential. But really the person that's taking care of you should be your partner. It should be somebody who is like I say with midwifery, you're the expert at you, and I'm the expert in the you know the science-y stuff. And together we can we can do things, but I don't but I'm not the expert at you. So you have to be able to tell me what what what's going on with you.
SPEAKER_00I think all in all, it's being your own advocate and not being afraid of being your own advocate.
SPEAKER_03Yeah, and I wish it wasn't that way. I wish you didn't have to be so, like, you know, but that's that's that's that's how we get better. I think if people know that they can demand better and that they deserve better.
SPEAKER_00That's it, folks. But I can't leave this two-part episode of Midwives Doula's Maternal Care Oh My without a little recap to get you motivated. So maybe you're thinking, what policy changes are needed to improve maternal care delivery? I'll lay it out for you, one by one. So, one, enable clinicians to practice at the top of their license without artificial barriers, and enable patients to have access to a range of providers that are the best to meet the patient's needs. Two, provide health insurance coverage to all pregnant people throughout pregnancy and at a minimum the first year after birth. 3. Ensure the appropriate education of patients both in terms of birthing options and throughout pregnancy and after, so people know what to look for. And then finally, care models that provide the needed range of services, including home visits after birth, to fully support the full family. Alright, there you have it. So let's get moving. The Adromatus Way is produced by me, Liz Church. Editorial assistance for this episode was by my fantastic team at Adromedas. I would like to express our heartfelt appreciation to our guests who've shared their expertise, stories, and insights with us on the podcast. And finally, a big thank you to our listeners. Your support and engagement have meant the world to us at Adromatus. We're a boutique consulting firm with the imperative mission of creating healthier, more resilient, more equitable communities. I encourage you to connect with us. Let's continue these conversations and work together towards positive change. You can listen to all of our previous episodes on our website, Adromatas Consulting.com slash Adromatas Dash Way. That's A-R-T-O-M-I-TOS. We can also be found on Apple Podcasts, Spotify, Amazon Music, or wherever you get your podcasts. We'll see you next time.
