ORLANDO, Fla. (AP) — Midwife Jenny Joseph touched Hasna Mixon's pregnant belly, then turned to the 7-year-old boy in the room and asked, “Can you help me examine the baby?”
Joseph placed his tiny hand in hers and used the fetal monitor to search for a heartbeat. “I can hear you!” he said. A fast, steady thump echoed through the room.
It was a full-circle moment for midwife and patient: The two had first met when Mixon was an uninsured teenager seeking prenatal care during her second pregnancy with a boy. Joseph has been on a mission for decades to guide patients like Mixon safely to parenthood through a nonprofit that relies on best practices learned in Europe, which experts say offers an answer to the American crisis.
“I think there's a maternal and child health emergency here,” said Joseph, a British immigrant. “It's not just frustrating, it's criminal.”
The Biden administration, which has made maternal mortality a priority in this year's election, acknowledges that the U.S. has one of the highest maternal mortality rates among wealthy countries, according to the World Health Organization and U.S. health officials. The U.S. maternal mortality rate is around 20 deaths per 100,000 live births, compared with around 50 for black mothers, according to the World Health Organization and U.S. health officials. In some European countries, maternal mortality rates are in the single digits.
Studies have shown that the majority of pregnancy-related deaths are preventable, and public health experts blame the high rates in the U.S. on a variety of issues, including inequities in access to needed medical care, systemic racism, sometimes poor quality medical care, and an increase in chronic health conditions among women of childbearing age.
Experts believe that solutions from abroad could be applied in the U.S. For example, many European countries offer better access to prenatal and postnatal care provided by both doctors and nonphysicians such as midwives, said Dr. Laurie Zephirin, senior vice president at the Commonwealth Fund, a nonprofit that studies maternal and child care in countries.
Marie Jean Denis (left) is examined by Jenny Joseph, head midwife and clinic director at Common Sense Birthing Clinic. (AP Photo/Jon Laux)
Joseph's organization, Common Sense Childbirth, is a small-scale example of this type of care.
The facility includes a clinic, birth center and training facilities for health care workers. The midwives who run the program serve vulnerable patients who other facilities turn away, including those who are uninsured or don't seek prenatal care until late in their pregnancies.
About half of his patients and many of his staff, including Joseph, are people of color, and while research shows that black Americans tend to have less trust in the health care system than white Americans, Joseph makes it a priority to build trust.
Jenny Joseph (back row, left), head midwife and clinic director at Common Sense Childbirth Clinic, talks with client Regine Barramore as her husband, Scott, holds their 6-week-old daughter, Yaharais. (AP Photo/Jon Laux)
“My model has four tenets: access, connection, knowledge and empowerment,” she says, adding that some patients “cry because they've never received that care or respect.”
All of this translates into better outcomes, Dr. Joseph said: In nearly 26 years of treating thousands of patients, she and her colleagues have never experienced a maternal mortality.
Reaching Zero
Maternal mortality rates (the death of a woman from complications of pregnancy or childbirth during or within 42 days of conception) are on the rise overall in the U.S. Approximately 700 women die each year, and another 60,000 suffer related injuries or serious complications.
A recent controversial study blamed the rise in deaths on changes in recording methods. The National Center for Health Statistics also recommended adding a “pregnancy checkbox” to death certificates to correct the undercount. But the Centers for Disease Control and Prevention and many doctors pushed back because the study suggested the birth rate was around 10 per 100,000. Some say the actual rate may be somewhere in between, meaning it's still higher than in other wealthy countries.
Midwife Stephanie Wood examines Courtney Knight during a prenatal checkup. Midwives at Common Sense Childbirth strive to provide high-quality, accessible care. (AP Photo/Laura Unger)
Experts say U.S. maternal deaths remain high despite proven ways to prevent maternal deaths and injuries, including ensuring quality medical care during birth, getting to know patients well, addressing issues like addiction and malnutrition, and providing care and support after the baby is born.
One of the most important things is to ensure that everyone has access to regular prenatal care, and this requires that there are enough health care providers.
Consider Norway, which has the world's lowest maternal mortality rate of zero, universal health coverage means people get free antenatal care at local health centres and, like Sweden, Germany, France and the UK, a plentiful supply of midwives.
According to a Commonwealth Fund study, Norway has 13 obstetricians and 54 midwives per 1,000 births, compared with 12 obstetricians and 4 midwives in the United States. The March of Dimes says that more than one-third of U.S. counties have a maternity shortage, and has recommended consolidating and expanding midwifery programs in all states.
Ruusa Sofia Tikkanen, a doctoral student at the Centre for Global Health Inequalities Research in Norway, said regular access to care for all pregnant women, regardless of their economic or legal situation, means problems are detected and treated early. She said immigrants without permanent residency have the right to the same prenatal care as other immigrants, including access to interpretation services if needed.
“Maternal mortality is a completely preventable event if you have access to basic health care,” Tikkanen said. “Not high-tech health care, but basic health care.”
What happens during and after birth also makes a difference: Caesarean sections are more likely to have complications than vaginal births, around 16% in Norway and 32% in the United States.
Midwife Serena Brown examines Kaylee Stirrup during a prenatal checkup. Midwives at Common Sense Childbirth strive to provide quality, accessible care. Experts point to the nonprofit, founded by British immigrant Jenny Joseph, as a model to help reduce maternal mortality, Tuesday, June 25, 2024. (AP Photo/Laura Unger)
Scandinavian countries and many other European countries offer generous paid leave, which studies have linked to better postpartum health. Norway mandates 86 weeks of maternity leave, parental leave, and home care leave. The United States has no such requirement.
Virginia Kotzias, who grew up in the US but now lives in Norway, has had two early miscarriages and said she had the option to stay in the hospital, but chose to do so the first time because she was scared.
“I had midwives on call throughout the 13-hour miscarriage process,” Kotzias said, “and painkillers. And I left the hospital with no bill.”
She said that during her two full-term pregnancies, she had access to prenatal care by a doctor, midwife, or both, and that because of her chronic health conditions, she also had regular visits with a high-risk obstetrician-gynaecologist, so “I felt very well taken care of.”
Kotzias was also able to take “tiered” sick leave if she felt nauseous or fatigued, and worked 80% of her regular hours, with the rest of her salary paid by a state benefits system.A few days after her baby was born, a midwife visited her at home to assess any post-natal physical or psychological problems and to check on her baby.
“I'm really grateful that Norway values and prioritizes families,” she said. “From the moment the stick turns pink, there's a really strong support system that tries to make it as easy as possible for families to succeed.”
“You have to start somewhere.”
But experts say it's possible to reduce the death toll, even in America's fractured health care system.
In Florida, where maternal mortality rates are higher than the national average, Joseph's organization relies heavily on charity, which makes up about half of its $3.5 million budget, allowing the clinic to accept patients who can pay little or nothing and allowing its midwives to spend more time with patients than most obstetricians.
Marian Knight, professor of maternal and child health at the University of Oxford in the UK, said research has shown that for women without major health problems, midwifery care is cheaper worldwide than obstetrician-gynaecologist care and leads to fewer medical procedures such as caesarean sections, a pattern that has also been seen in US studies.
Some Common Sense Childbirth patients experience complications and are referred to specialists, but most choose to give birth at local hospitals, where Joseph has strong ties, rather than in Common Sense's delivery room, and then return to the midwife for postpartum care.
Jenny Joseph, head midwife and clinic director at Common Sense Childbirth Clinic, talks with clients and staff. Midwives who run the program welcome vulnerable patients who other clinics would turn away, such as those who don't have insurance or don't receive prenatal care until late in their pregnancy. (AP Photo/John Laux)
“Jenny's NHS,” Joseph said with a sly smile.
At her Orlando and Winter Garden clinics, she instructs her front-desk staff to be welcoming, even when things are busy, encourages women to bring their kids to appointments instead of scrambling to find childcare, and keeps a corner of the waiting room stocked with toys.
“They're not just looking out for your pregnancy, but other things too,” said Mixon, 24, who is now on Medicaid and began her prenatal visits around the eighth week of her pregnancy.
Marie Jean Denis (left) embraces head midwife and clinic director Jenny Joseph (right) on the way out of a consultation at Common Sense Childbirth Clinic. (AP Photo/Jon Laux)
Joseph hires empathetic midwives, one of whom gave birth to the first of her six children at age 16 with the help of a midwife, and another who was born to a teenage mother, grew up with little money and joined the organization to help people who often don't have access to midwifery care.
On a recent afternoon, Kaylee Stirrup came into the clinic for a check-up a few weeks before giving birth to her first child. During her pregnancy, she had struggled with uterine fibroids, painful ligaments, and shortness of breath. She said the midwives had given her “tremendous support.”
Experts say health care workers are more likely to spot potential problems if they listen carefully to their patients and take what they say seriously.
Before examining Stirrup, midwife Serena Brown asked, “How are you feeling?”
Midwife Serena Brown talks with Kaylee Stirrup during a prenatal checkup. Midwives at Common Sense Childbirth strive to provide quality, accessible care. (AP Photo/Laura Unger)
“I'm feeling very nervous and excited,” the 31-year-old replied. “As the day draws closer, I start to worry about whether I'll be able to endure the pain.”
“It's normal to feel nervous,” Brown reassured her, “but you just have to be open to the whole process. You can do it. You can do it!”
Brown said she is always amazed by the strength of her patients. She recalled one teenage girl who had just gotten out of prison who overcame drug addiction and gave birth vaginally without the use of painkillers.
Joseph has no plans to return to Europe: She is opening a midwifery school, organizing training programs for other health professionals and convening a national group of experts and advocates via video conference to share ideas for improving maternal health and eliminating disparities.
She thinks America needs more of her.
“This is literally my life's work,” she said. “I won't stop until it's done.”
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This article is the first of a two-part series examining how the United States can curb deaths due to pregnancy and childbirth.
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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute's Science Education Media Group. The AP is solely responsible for all content.
