The Southern Birth Justice Network (SJBN) is taking aim at Jackson Health System to make a point of pushing for policy shifts around maternal health care for Black mothers and babies in Miami-Dade County, amid existing racial disparities.
Last week, the local Black-led nonprofit announced a new initiative funded by the Robert Wood Johnson Foundation – The Miami Birth Justice Initiative. Over the next three years, members of SJBN, in collaboration with Catalyst Miami and the Florida Health Justice Project, will support and educate Black women, engage with the community and advocate for sustainable solutions in local hospitals, starting with Jackson, one of the nation’s largest public hospital systems.
SBJN is calling for doulas to be allowed in Jackson’s delivery rooms during childbirth, a stop to unnecessary Cesarean sections and health care workers to listen to and assist Black women during the birth process free of discrimination or bias.
Better care with doulas & midwives
A growing body of research shows that having midwifery and doula care during birth is important for Black women, and could help combat racial disparities plaguing the health care system. Doulas should not be seen as an additional person in the room like a family member, because they are a necessary part of the birth team as non-medical support people, says Jamarah Amani, a midwife and the executive director of SBJN.
“As advocates, doulas are key to reimagining health care. Doulas teach their clients about transmitting pain into power,” she said. “Midwives and doulas often work together, and we are transforming health care one birth at a time in home, birth center and hospital settings.”
Jackson Memorial and Jackson North Hospital employ certified nurse midwives and work with doulas. Dr. Michael J. Paidas, chair of the department of obstetrics and gynecology at both the University of Miami Health System and Jackson Health System, says great progress has been made with the Center for Haitian Studies as a conduit for this type of maternity care.
“We embrace and we love the midwifery concept,” Paidas said. “Doulas are so important and I see our mission as connecting with the community. I see the doulas and midwives and patient navigators as a link between the patients that we have on the labor floor, in the obstetric arena and in the community.”
But because of COVID-19, many hospitals like Jackson have implemented limits on the number of accompanying people in a delivery room. Now, as the pandemic has been winding down, many hospitals have eased their restrictive policies, yet at Jackson, that number continues to be just one support person, compelling patients to choose between a partner, family member or doula.
Are C-section rates too high?
Nationally, about 700 women die each year as a result of pregnancy or delivery complications, with Black women three to four times more likely than white women to die from pregnancy-related causes, according to the Centers for Disease Control and Prevention (CDC).
The CDC cites a number of reasons for Black maternal mortality, including underlying chronic conditions, variations in health care and implicit bias. But one factor that contributes to these racial disparities are cesarean sections, which SBJN hopes will be greatly reduced in the county’s hospitals.
C-sections can be medically necessary for a high-risk pregnancy such as multiple births or placental problems. However, the procedure is overused at alarming rates, exposing mothers to much greater risks – such as infection, damage to the bladder, blood clots and hemorrhaging – than those potentially experienced with vaginal deliveries.
The current percentage for C-sections combined at Jackson Health System is 37.53%, according to statistics provided from the hospital. The state’s average cesarean delivery rate is 36.5%. Numbers from January to October 2021 put Jackson Memorial at 39%, Jackson North at 42.8% and Jackson South at 24.8%.
As for the differences in percentages at each hospital, Paidas explains that they’re bound to happen, but what can be done is to put protocols in place across the entire system so that everyone can “operate from one lens.”
But there has been a steady decline in C-sections at Jackson. One factor Paidas credits for the decrease is the reduction of early-term deliveries, which are unnecessary procedures where an induction or C-section is performed prior to 39 completed weeks of gestation.
“We make sure that the indications for going to deliver, whether vaginal or cesarean, they’re valid, so you want to make sure of not only the timing, but also the indication,” he said. “We want to let Mother Nature take its course as much as possible and then intervene when appropriate.”
Traumatic childbirth experiences
When Rebekah Antoine, a doula and SBJN member, gave birth to her firstborn child in 2015, the senior-year college student was not prepared for the reality she would face in the delivery room at Jackson Memorial Hospital.
She says the doctor was supposed to check her cervix to see how far dilated she was. He ruptured her membrane instead, which led to a cascade of events beginning with a dangerous umbilical cord complication known as a cord prolapse, a potentially fatal obstetric emergency for the baby. She says she wasn’t informed of what had happened at the time, nor did she consent.
“They had to rush me to an emergency C-section,” said Antoine. “Once I got into the operating room, no one was there to tell me what was going on and what was happening. All I can see is the nurse scrambling trying to get the anesthesiologist on call, but he is nowhere to be found. Now I’m crying. No one is explaining [to] me what is going on.”
Although Jackson Health System cannot detail a specific patient’s experience or speculate what happened to them due to patient privacy, The Miami Times asked Paidas about scenarios and protocols put in place as to when something goes wrong during labor at the hospital.
“We’re the largest medical university health care complex in the region and, as a result of that, we see the largest percentage of the highest-risk patients that are in the area.,” he said. “We are used to being in this kind of high-risk setting, perhaps more stressful environment. However, we also feel it’s our mission as well to provide the very best comfort and communication and safe surroundings to our patients. Everyone has to do their very best to communicate even in that type of setting; you know, what’s happening and what’s going on, and admittedly, it’s a stressful scenario, we understand that, for our patients and for us.”
Antoine’s first birthing experience left her feeling violated, which led to a long-term battle with postpartum depression and anxiety, but learning about what happened to her helped with her recovery.
“After experiencing the level of how care is provided and our standard hospital system, especially for Black women, I’m like, it can’t be like this. We need to do better,” she said.
After the birth of Antoine’s first child she would go on to put her pre-med studies on pause when she gave birth to two more children – one at a hospital in Gainesville, Fla., and another at home with a midwife. Trying to decide where to go with her future, she opened herself up to different career options within the health field that allowed her to work with pregnant women. That’s when she found out about doulas, nonclinical professionals who provide prenatal, labor, and postpartum support and guidance to women. She is now a doula working toward becoming a midwife.
“Finding out after my grandmother passed that she was a midwife back home in Haiti, I really came to that spiritual calling and the action to be like, you are in your community. If not you, then who?” Antoine said.
Like Antoine and many Black women who have brought life into the world, Yamesse Johnson was all too familiar with the dismissive treatment she experienced due to what she believes was racial bias. The idea for the Miami Birth Justice Initiative came after SBJN held a young mothers panel last year which included Johnson and two other mothers who all had experiences at a Jackson hospital.
Johnson gave birth at Jackson seven years ago at 15 years old. She says she shares her traumatic experience in the hope that it will help make a change and keep what happened to her happen to anyone else, which is the reason she connected with SBJN.
In her situation, she says there were two or three nurses in the delivery room.
“No one acknowledged me, no one talked to me. It was as if I wasn’t there. But everybody knew what to do about my body. Everybody knew what was going on, but me,” Johnson said. “Although I was aware of the pregnancy and the birth and labor and contractions, there was a whole lot I did not understand medically and physically with my body at the age of 15.”
She described her unease with doctors as she pleaded to get any kind of information, such as what was going on or what she was supposed to be doing. All she could feel was movement in her stomach. It wasn’t until she actively tried to get up from the bed that someone acknowledged her.
She was supposed to leave the hospital with two newborns, but only left with one.
In obstetrics, situations – especially in a high-risk setting – happen in a split second, Paidas explains. But even during those times, health care workers in the room have to do their very best to communicate with the patient as things are happening.
“We have to be attentive to our patients. If they’re trying to express something, it’s on us to be sure that we’re understanding and we’re communicating back and forth,” he said. “At the end of the day, it’s really about providing the very best compassionate and empathetic care to our patients.”
Next steps to achieving health equity
“We talk a lot about mortality, but what we don’t talk about a lot is morbidity,” said Amani. “People that are living with the long-term consequences of poor quality care. You know, chronic conditions, mental health issues, being disabled in different ways. Those are the things that we also see alive in our communities, not just the deaths, although those are important.”
As a youth-centered organization, the executive director added that there are young moms, even in their teens, who are telling her, “The next time I go and give birth when I’m in my 20s, I want it to be better.”
Amani became director of SBJN in 2010, but the organization was founded in 2008 by one of her mentors, a woman training her in midwifery who became ill and decided she couldn’t run the nonprofit anymore – so she passed it to Amani and a colleague. The two were running it together for a while, but it’s been Amani alone at the helm since 2015.
She says the organization is in communication with doctors at Jackson Health System and have been invited to make a presentation about birth justice at a meeting.
“Particularly doctors and nurses want to see things change,” said Amani. “We’re hoping that we will get a meeting with the higher-ups at Jackson and be able to really talk about real policy change and get them to officially adopt our Birth Justice Bill of Rights into their policies.”
The Birth Justice Bill of Rights is a list of 22 amendments to be utilized as a tool to remind a patient of their rights and to advocate for the respectful care they should be receiving.
Paidas says he’s looking to engage with SBJN and would be happy to have the organization reach out specifically to Jackson Health System and not just employees.
“With respect to the Black mamas and the huge disparity that we have here, it is very deeply important to all of us, and I can tell you as someone that runs the department as chair, the newest faculty members that I’m bringing on that care for high-risk pregnant women, one is African American and the other Hispanic. Two women,” said Paidas. “It’s so important that our department, the health care providers, reflect the community that we serve, so it’s a journey. We have a lot to do, but we are thoroughly committed to it.”