Access in Healthcare

I have several posts written that haven’t been posted.  This is partly due to me trying to find my space in this new space, and partly because as we learn about and settle into a new practice in a new community, there is not much time for editing.  This article is from March of 2018 and examines our model of care through the lens of one of our programs, group prenatal care.  This program and many of the classes that spin off of requests made in the group, are open to all families, even if they are not in our care.  If you are in Memphis and want to join us for a program or come into care, please contact me.

As a community-based midwife I have been drawn to, pulled, and stewed in the places where midwifery and public health come together like a heated 32-beat tango.  Connected, dependent, free-spirited in nature yet grounded in science, this form of perinatal healthcare is my deepest heart’s work.  In Seattle our clinic, situated in the heart of a medically underserved neighborhood, was founded with the basic premise that we could reimagine healthcare.  The families, colleagues, health systems, and communities that participate in the care are committed to this mindset or to providing space within a more rigid system where we can explore the outer bounds of our ideas.  That organization continues to evolve and stretch into places and ways of being present for families and communities that astound me.  There are other midwifery-led clinics innovating and serving their communities around the US. Midwives are busy people, working through the wee hours trying to make a dent in maternal and infant health outcomes. In Memphis I am again working in an environment where that element of possibility leads us forward and exposes innovations as they naturally arise from our efforts to meet the needs of the families we serve.

Over and over again, wherever I am, I am taught a singular lesson about imagination and healthcare.  I am taught to follow my commitment to seek the strength and health of families I serve, even when it is not arranged as we are told it should be. When I first learned about labor I understood it to come in phases and stages which one neatly progresses through.  My doula certification required rote memorization of these steps, the signs of each one, and how to provide physical and emotional comfort and support for the pregnant person through labor and birth.  Yet I did not attend my first birth as a trained doula.  I sat in a small hospital birthing center with my brother and sister-in-law while they labored and birthed my nephew.  It was not my response to the phases and stages that provided her comfort.  It was my presence and attunement with her and my brother, my faith in her abilities, my interest in seeing my brother become a father from a place of strength, and my keen sense of wanting her to have a meaningful and timeless experience that mattered.  This experience was the first of many that taught me to look at pregnancy, birth, and early parenting as equally whole, layered, complex, and varied as the mothers and fathers I served. As equally needful of a response that understood both the expected norms and the reality and potential of the person in front of me.  I have witnessed alchemy a thousand and thousand times.  A shifting, morphing, and transforming moment.  Sometimes it is in prenatal care when a connection is made, sometimes during labor when the power of contractions takes a mother away from us and she retreats to a private universe, sometimes when she breathes her first breath as a mother to her baby now here, warm in her arms.

The science of pregnancy and birth is remarkable.  It allows us to support, aid, and even rescue mothers and babies every day.  As providers what do we have to learn from but the tools we are given?  Our books, our lectures, our machines that keep us moving in linear phases and stages through expected norms.  Those great teachers of mine gave and continue to give me command of the skills I need to care for families safely during their perinatal year.  But those other great teachers—the mothers, the fathers, the babies—they have informed me too.  From them I learned that the work I feel pulled to—this creation of micro-systems where families don’t just survive but really thrive and come into their fullness does not exist or occur in a linear progression.  It lives in the expansive reaches of our imagination.

It lives in discarding programs and services that always meet the needs of a linear and ordered system but rarely the true needs of the people in it. 

For many years I have run models of group pregnancy and postpartum care.  I have tested and tried curricula written by organizations committed to improving maternal and infant outcomes.  They have demonstrated success in these important areas.  The organizations that designed them have a lot of rules—so many people need to be present, they all need to be pregnant within about the same gestational age, they are assigned topics and facilitated, there is required attendance at a specified number of groups, they replace the individual visits with the midwife or doctor.  This makes perfect sense if we are trying to facilitate a group that teaches to the phases and stages of pregnancy and birth.  It makes perfect sense if we read any of the text books.  They all highlight “expected changes at this time” by trimester.  Naturally, we group pregnant people together who are the same gestational age experiencing the same changes.  We can conveniently teach to these issues and this does provide a kind of comfort—knowing that you are not alone in your changes and learning to adapt to them.  However, I have never been able to exactly stick to the prescription or the curriculum.  Usually because someone wants to participate but for work or life or financial reasons they can only get to a group that is running at a certain time.

Not the group they are slotted to, but to the group that is accessible when they can access it.

People arrive to group care full of ideas, needs, and questions that are totally unrelated to any prescribed content.  So what if the curriculum is the content of their lives in that moment? Ours is.

Now buckle up, I’ve said this before but let’s discover what it means:

When it comes to maternal and infant health,

there are only no answers if all of the answers are “no”.

If you are running a community-based clinic which fundamentally believes in access to care and services, you say yes a lot.  You say yes when the curriculum says no. You say yes when it means someone is going to skip a phase or jump over half of the progression.  You say yes when someone can come tonight but not again for six months.  You say yes when someone has never shown up but wants to sit in group now.  You say yes when a grandmother-to-be shows up with her pregnant child to explore this new model of care.  You say yes when a patient calls and tells you their car won’t start and they are out of money and they need a ride—even when it means the group will wait an extra five minutes to start. You say yes when a new mom shows up because she was lonely and knew that there was a prenatal group today.  You say yes because connection is the remedy for isolation and prevents depression, and her mental health matters.  You say yes because her presence there teaches the expecting mothers about what it looks like to care for a baby over the course of two hours in ways you could never script.  You say yes because someone else, maybe even someone else’s grandmother will hold and rock and walk that baby and tell her what a good job she’s doing.  You say yes because there are not limits on your imagination and you don’t see the people who come into care as limited, as broken, as needy, as powerless.  Your system does not rely on anything that resembles a normal healthcare delivery experience.  Why should it?  You are unbound so you are allowed to follow the dictates of the moment, the needs of the individual, the kindness that needs to manifest from your own heart.  And you are unbound so you can think with curiosity about the clinical presentation of disease, disorder, and dysfunction.  You are unbound so you can think about prevention and isolating a remedy that leads to health and not merely symptom management.

You can accomplish all of this in deep partnership with patients, clients, and their family members. 

And here’s what I’ve learned from saying yes.  As a provider, it is no toll on me to do so.  I don’t mean to be romantic about it–this is hard work.  It is also a remedy, a boon, and a manifestation of my humanity.  The people I work with feel the same way.  They are fanned out all over the city right now as you’re reading this bringing food, giving rides, sitting and listening, available, and present.  And in this example, of group prenatal care that evolves into group perinatal, parenting, god-parenting, and grand-parenting care, each person present feels their experience reflected in the shifting, morphing, and transforming moments of others.

We are learners and teachers, we are wise and vested and new and afraid.  We see where we are going, we feel where we have come from, we sit where we are.

We recognize the suffering and joy in others and freely bestow and receive compassion in that space.  This is a platform for health.  This is our platform for healthcare.  And this is one reason why I believe families in our care emerge with health outcomes that do not reflect the societal norms even though they have extraordinary life stressors. They are at risk for all of the risks, yet they very rarely manifest any of them.  This form of midwifery exists at the intersection of love and justice and healthcare.  It is not about leveraging the cost of healthcare, though it costs less. It is not about the birth. It is about good and even robust physical, emotional, and mental health where the right kind of birth in the right place for each family is the natural outcome of a platform where every idea has the potential to become a solution and every person is worthy of our best yes.

Author: Midwifery

Jodilyn is a licensed midwife (WA, TN) and certified professional midwife. Recently relocated to Memphis, TN, and passionate about the intersection of social justice and perinatal healthcare. She owned Essential Birth & Family Center in South Seattle's Seward Park neighborhood. She is co-founder of South Seattle Women's Health Foundation, an organization dedicated to providing midwifery-led maternity care in a collaborative community-based setting and to increasing capacity within the community to support healthy birth and breastfeeding practices.