Advancing the Profession of Midwifery: A Conversation with Jennie Joseph

This is the second part of a two-part interview with Jennie Joseph. You can read the first part of the interview here.

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The profession of midwifery is centered on a long-standing tradition of providing care to women and birthing people throughout their pregnancies as well as attending to the needs of parents and their infants postpartum. Though midwifery has been shown to reduce perinatal health disparities and help address provider workforce shortages, most people in the United States do not have access to midwives. In fact, according to the American College of Nurse-Midwives, among high-income countries, the United States has the smallest midwifery workforce in the world.

For midwifery to be an effective tool to combat the maternal health crisis and help dissipate maternal health disparities, we need more midwives from traditionally underresourced and underrepresented groups. However, according to data from the Commonwealth Fund, childbearing people of color experience the largest gap between the demand for midwifery care and access to it. 

Jennie Joseph, a nationally and internationally recognized midwife, is working to expand access to midwifery by broadening the maternal care workforce. Her work—which includes the establishment of the Commonsense Childbirth School of Midwifery, The Birth Place; the Easy Access Clinic™; as well as the National Perinatal Task Force—is helping to create new frameworks and pathways for the provision of equitable maternal healthcare. Jennie Joseph spoke with NPQ about this important work.

Tonie Marie Gordon: From your perspective, what issues are at the heart of the maternal health crisis in the United States?

Jennie Joseph: The lack of midwifery in the US, I think, has been lethal. I think it’s detrimental that we have such a dearth of midwifery providers because that means that women are not being taken care of, that birthing people are inside of a system that is not conducive to their care. The cascade of interventions that are standardized in a hospital setting are not part of a midwifery model. 

Midwives are supportive of the birthing process, watchful, and ready to intervene if necessary. An obstetric model is built on interventions. And that approach has expectations around the timeline. For instance, if the birth is not progressing at a particular pace, you will have an induction. If you are not going into labor at a particular time, you may have a C-section. All the interventions can compound and, suddenly, the mother is now experiencing complications.

The lack of midwifery in the US, I think, has been lethal.

Approximately, one in three American women are having their babies by C-section instead of a vaginal birth. In the same populations matched demographically across the world, for example, they’re not having the same rate of births by C-section. So, this issue is not physiological, there’s something else going on. 

I believe that part of what’s going on is the lack of midwifery and the midwifery model being a standard model of care, but also the fact that we have all agreed, whether on purpose or by accident, that this is okay, that birth is a medical emergency. We have agreed that physicians and nurses and other healthcare providers must operate in fear of something going wrong, fear of litigation if something goes wrong, that they must operate from a place of risk.

There are power dynamics operating inside of institutions where racism, classism, and discrimination are baked in. These factors are impacting this maternal health crisis where we have the largest number of women dying or being harmed during childbirth in the developed world. With every resource that we have with all the trained and credentialed professionals in place to support this process, somehow, the US is dead last as far as developed nations in our birth outcomes and the health of the people who are delivering babies in this country. And it’s not being addressed in any meaningful way, because the statistics are worsening. Morbidity and mortality are increasing every year. We must confront the horror in that. 

But also, we must remember that for three to four times as many Black women or Indigenous women to die during pregnancy, birth, or postpartum, the only other reason for that to be a fact is because we have a system that has discrimination built in. There is racism, classism, a lack of respect, and a lack of dignity, and listening to pregnant women. We’ve been told over and over why we are losing our mothers, but it can only stand if we collectively agree that we can’t do anything about it. Until we agree and understand the root causes, we aren’t going to be able to do anything. And one of those root causes in the US is the eradication of midwifery.

TMG: Could you tell me more about your approach to care provision, or, what I’ve seen referred to as The JJ Way®? 

JJ: While running a clinic in the Orlando area, running a birth center, doing home births, trying to serve people who are in desperate need, people who were being turned away in other sources of care, I found that I needed a framework for more meaningful interventions. I was thinking that the birth itself might be the intervention, but I realized that wouldn’t be enough because only a small percentage of folks in the US are open to community birth. In the US, the majority still want to be in a hospital environment for labor and delivery. So, I found a way to offer easy access, a no-drama model to provide women and birthing people prenatal care, a hospital birth, and postpartum care with the midwife so they’re cared for through each stage of pregnancy, birth, and postpartum by different providers.

We begin with the prenatal course, based on a midwifery model; it’s one-on-one and allows for interaction, it allows the midwives and birthing people to start building a relationship, there’s a safety that comes with being treated with dignity and respect. And I found that was the piece that people were searching for. They weren’t that hung up on which hospital or birth room they were going to be in. Rather, they needed someone to listen to them. They needed true support. They don’t want to be judged; they don’t want someone wagging their finger in their face. They are doing the best they can, and they want to be met where they are. This is also the prenatal part of the model.

The second and most important part of the model was providing a liaison with hospital systems. Since the nurse-midwife services that are in place to deliver babies weren’t honored, we worked with doctors who were willing to receive patients to deliver them on behalf of the midwife. We make sure that women have their prenatal chart, all their records, all their labs, ultrasounds, and everything else they need to get into the hospital environment safely. But liaising with providers in a hospital setting takes midwives out of the picture. And it made it so midwives can’t bill for the delivery. We let go of the billing because even though it was horrible for us, it was what’s right for the patient.

With the model I’ve described, every patient went to term, even though Black women often have pre-term babies. The NICUs [neonatal intensive care units] are full of Black and Brown babies. With this model, we don’t have that problem, we have full-term babies with healthy weights. We also don’t induce labor; we don’t force a birth at 37 weeks. We just wait for nature to take its course.

After birth, the doctors return the patients back to the midwives who provide care through the postpartum period. With this approach, we spent time being with women in postpartum and we’re seeing much healthier postpartum recovery. Our mothers were not suffering from depression. They weren’t having trouble with breastfeeding. They were getting back on their feet. They were fine. These results are because we provide midwifery support throughout the continuum of maternal care, not just visits at six weeks and running some tests. That’s not real care.

The JJ Way® built out a set of wraparound supports inside of a system where there is no support. Even though I started doing this work in the early 2000s, the four main tenets of the JJ way are still in place today. The four tenets that set this program in motion are access, connection, knowledge, and empowerment.

Regarding access, no one is turned away. When women and birthing people come in the door, we troubleshoot from there and see how we can help. Connection is about trust. We trust that our patients know what they are talking about and what they are asking for, and our patients trust us to be able to support them in that. That was the connection. The knowledge is shared between both parties: the midwives and the clients. We’re asking questions like, what do you need to know about us? What do we need to know about you in this exchange of knowledge?

The last tenet of my unique framework, The JJ Way®, is empowerment. We encounter our patients outside the system, and we empower them outside the system. So that inside the system, they can fend for themselves. For example, for the women and birthing people I work with, the C-section rate is under 20 percent. Even during the COVID-19 pandemic, it was around 17 percent. Many of the C-section rates around the country are 30 percent or more. In some areas of the US, it’s 34 or 35 percent, which is more than one in every three mothers. Our low rates of C-sections are evidence of this empowerment.

There was also a lot of work involved in gaining trust within hospital systems. We were asking doctors to collaborate with us, to receive the patient as part of a larger process. The way we work made doctors more comfortable, too. We provided access to patients who had everything in place, who are healthy. These aren’t crisis cases or complicated cases because there was no prenatal care or there was inadequate prenatal care. We share information, we’re ready to support. The relationship made patients feel safe to be delivered by this person. And doctors felt safe delivering the babies of the patients. 

We began applying The JJ Way® to providers as well, and that was also transformational. This broke down hierarchies in the hospital system and allowed people to work inside of their power, in their respective role within the maternity care spectrum. Medical assistants were blossoming because they were empowered to work with these families one-on-one and share their lived experience, share their expertise, create another pathway of support so that the clients began to depend on the other staff members just as much as they did the midwives. They were able to depend on medical assistants, childbirth educators, everyone was involved in this circle of care that wrapped around the patient, placing them in the center. Everyone had a part to play. And people in other roles were able to do their work in a different way, with more professional growth. It created interests in different career paths like midwifery or inspired more people to want to be a nurse or a doctor. 

These midwives are forced to get going and hope for the best, even though various factors are against them.

Through working with healthy, full-term patients, we also helped doctors. To this day, doctors tell me that they loved receiving my patients because they got to do so much. They were able to really understand birth because of working with empowered patients who knew what they wanted, were educated in the process and ready. Because they weren’t doing so many C-sections, they were able to see what physiological birth looks like.

TMG: What are your thoughts about the future of the maternity care workforce and the outlook of the profession of midwifery, especially in the United States? 

JJ: It’s quite a dilemma because we are trying to attract more people into midwifery. We’re trying to grow the profession of midwifery. And we have a dilemma in that we have two aspects of midwifery in this country: we have a growing number of folks going the nurse-midwifery route, which allows them access to hospital practice and allows them to practice [across disciplines] with ob-gyns [obstetrician gynecologists] in private care and in clinic-based and hospital-based care.

The nurse-midwifery profession, unfortunately, because nursing is part of it, belongs under physicians within the hierarchy of medical professions. It’s not autonomous in the way midwifery is around much of the rest of the world. The second way that midwives are growing is in the community space. And the midwives who are not nurses are doing home birth or community birth. These midwives are either not nurses or if they have a nursing degree, they’re not using the degree. They’re using their midwifery certifications and training. The difficulty here is that, in the community space, they are relegated to being an entrepreneur. In that space, there just aren’t jobs for midwives. These midwives are forced to get going and hope for the best, even though various factors are against them. For example, commercial insurance will not reimburse them, and Medicaid reimbursements are quite modest. It’s difficult to make ends meet with that. 

And because there’s so little coverage for midwifery, it shows up as double billing for patients. People will think, why would I pay money when my insurance covers me to go to the hospital? Why would I take the chance of having two bills? To add to the difficulties, in the US, it’s not normalized yet to have out-of-hospital births with community midwives. All of this illustrates the challenges for someone who chooses this professional path. Many community midwives who are not nurses choose that path because they want to serve communities in need. And many of them are interested in the profession because of their own experiences and they want to offer their community a better option, a chance to not have the type of experience they’ve had.

Even with our successes, we are still underfunded and not able to build the infrastructure to support graduates after they finish. But we keep going because we have hope.

But the people who are interested may be marginalized, and for them, the cost of education is prohibitive. We try to offer as many scholarships as possible, but without financial help, the education is unaffordable for student midwives. If you get a scholarship or coverage for your student loans, you will still need a living stipend, because you can’t train as a midwife and do another job at the same time because the babies can come at any time. So, there is a significant barrier aspiring midwives have in terms of getting access to education, to training, and to the certification process. We’re also facing economic injustices. 

Whether you choose the community route, where you’ve got all those constraints, or the hospital-centered, medical route, where you’re spending a fortune on a degree, neither situation is conducive to midwives being empowered. 

Midwives also face discrimination as a profession. Many people don’t know what a midwife is, and they question it. The profession doesn’t need that. It makes midwives feel like, from a professional standpoint, they’re not safe, they don’t belong. There is also a lot of propaganda, myths, and tropes that surround midwifery. Midwifery will always be racialized in this country because it was the midwives of color that birthed this nation. Midwifery still has a stigma. 

We are training the community midwives, the direct-entry midwives. We [the Commonsense Childbirth School of Midwifery] are the first and only private school that is nationally accredited to train midwives in this manner. As a Black woman owning and running a school that is unique. And that speaks to, again, how the system is setup in the US. And even with our successes, we are still underfunded and not able to build the infrastructure to support graduates after they finish. But we keep going because we have hope. And we see, from a generational perspective, that this work will eventually take hold.