The Case for Making Respect Central to Care During Pregnancy and Childbirth

image credit DIANE von FURSTENBERG x #INCHARGE

The house call commenced with a dance party. Midwife Kimberly Durdin, a co-founder of the birthing center, Kindred Space LA, sashayed into the home of journalist and maternal health advocate, Elaine Welteroth, who beckoned in harmony with a rhythm and blues ballad, swaying and cheering to the music that set the tone for exactly the sort of relaxed and personalized antenatal visit that Welteroth had dreamed up and then manifested for herself. It was impossible to watch Durdin’s arrival to the home in a video posted to Welteroth’s instagram stories last month and not immediately sense an admirable warmth and intimacy between the provider and patient. Now Welteroth, who is in the latter stages of pregnancy, has conjured up a plan to help other pregnant people who want to experience their own versions of well-being during pregnancy and childbirth, just as she found for herself, through the birthFUND, a newish venture to sponsor midwife-led care for less privileged families. The birthFUND is neither the first nor only privately endowed organization helping underserved pregnant people to access midwife-led care - there are other similar community-based organizations across the country. But unlike other such philanthropies disbursing grants to pay for midwife-led care, the birthFUND has quickly risen to prominence propelled by the backing of powerful women with tremendous platforms, like CNN journalist Abby Phillip and tennis superstar Serena Williams. Phillip and Williams have each in their own way already meaningfully shaped the conversation around maternal health, particularly the experience of Black pregnant people, through an Emmy award-nominated documentary chronicling the rise of home-births and a widely-read and reported story for the US edition of Vogue magazine. Yet, as awe inspiring as the courage Phillip, Welteroth and Williams have shown in sharing their birth stories and then turning their cri de coeur into tangible action by launching a private endowment to support essential maternal health services, that the wealthiest country in the world should even need grant-making vehicles like the birthFUND in the first place should enrage us all. It is a damning indictment. A sign of the depth of despair because the 80% jump in maternal deaths noted between 2018 and 2021 that intensified during the Covid-19 pandemic means nothing else is working or working quickly enough to reverse our dismal maternal outcomes that citizens now feel they must take matters into their own hands.

“… that the wealthiest country in the world should even need grant-making vehicles like the birthFUND in the first place should enrage us all.”

But temporarily putting aside outrage fanned by the intractable maternal health crisis and withholding for a moment bitter lament that a means to replicate the vibe Durdin brought to Welteroth’s antenatal visit for every pregnant patient still seems far out of reach, what can we realistically expect the impact of the birthFUND will be? Convention dictates that the birthFUND is subject to evaluation for its effectiveness in meeting the stated goal of supporting less privileged families who desire to access midwife-led care, but it is too premature to make a determination now based solely on the number of families said to have received its support to date. Earlier this month, the birthFUND announced that it has amassed an endowment of $1.5 million since its inception in April 2024 and that by September 2024, about one-fifth of that amount had been spent on sponsoring midwife-led care plus in-cash and in-kind grants for 10 families. It would be unfair to compare this small number of families against a denominator as vast as the demographic targeted by the birthFUND that comprises some of the 40% of roughly 3.5 million births taking place annually in the United States amongst families that meet federal income eligibility criteria to qualify for Medicaid coverage. A more fitting yardstick may be the visible and discernible advocacy work being undertaken by stakeholders affiliated with the birthFUND itself to drive investment and legislation towards curbing preventable pregnancy- and childbirth-related deaths and illnesses. For instance, in recent days Charles Johnson IV and Jonathan Singletary, advisor and deputy director of the birthFUND, respectively, participated in a congressional briefing in support of the momnibus bill held for men already working in the maternal health space and aptly titled “Dad’s Got Something to Say.” With time, more formal inquiries seeking to seriously gauge the impact of the birthFUND are guaranteed and expectations will likely match its sleek entrance into the decidedly less glamorous milieux where too many pregnant patients experience illness and even death although the precise impact may still be complicated to parse. The mission of the birthFUND hinges on the global consensus - supported by evidence - that, in general, incorporating midwife-led care into maternal health services delivery leads to better outcomes but a closer look brings a bewildering picture into focus. In England, for example, where one-third of births in 2021 were supervised by a midwife, a much greater proportion than in the United States, the risk of dying during pregnancy and childbirth for Black women was still four times higher than for white women during the same period, suggesting broader systemic shortcomings that contribute to persistent maternal health disparities even in countries where midwife-led care is more common. Whether the birthFUND can extend its reach to help beneficiaries circumvent such systemic deficiencies remains unclear.

In the meantime, until a conventional evaluation of the birthFUND is completed, there is one reproductive injustice for which a remedy will emerge less likely through legislation and fiscal investment and more likely through a cultural shift, the stirring of which the birthFUND can be instrumental by invigorating a conversation about disrespectful treatment during pregnancy and childbirth. The reflections of Phillip, Welteroth and Williams revealed deep-seated sentiments about how they perceived obstetric clinicians to manage their childbirth-related morbidities and then discuss those complications with them in a way that either shielded (for Phillip and Welteroth) or exposed (for Williams) them to trauma. Publicizing these experiences and ingraining them into the mission of the birthFUND is not insignificant. One in six pregnant people in the United States reports some form of disrespectful treatment when seeking pregnancy-related care, such as verbal abuse (being shouted at or scolded by their maternal health care provider) or being ignored after requesting assistance, and people of color are more likely to report mistreatment. The manner in which maternal health care providers interact with pregnant patients - whether they are dismissive and too slow to respond to concerns or being downright impudent - has been implicated in adverse maternal outcomes. For Williams, the magic of childbirth by cesarean section had felt amazing until “everything went bad.” Reported to already live in fear of suffering another blood clot in the lungs, known as a pulmonary embolism, Williams immediately recognized the telltale shortness of breath which, to her, could only have meant one thing: a new blood clot had formed as she recovered in the hours following surgery. But Williams maintains that a nurse dismissed her alarm that she was having difficulty breathing and her conviction that she knew what was happening to her by attributing the symptoms to narcotic-induced delirium, an assessment that failed to account for Williams’ medical history, which included at least one well-documented past episode with pulmonary embolism. In cases such as Williams’, it is easy to simplify the inadequate response as a failure on the part of one nurse violating their professional code of conduct, but Lynn Freedman and Margaret Kruk proposed in the Lancet that undesirable behavior displayed by individual maternal health care providers occurs within a context in which complex personal, normative and systemic factors coalesce to permit disrespect in the first place. In other words, disrespectful health care workers are a reflection not just of their own personal failings but also of their problematic work environments. Therefore, a solution to disrespectful treatment during pregnancy and childbirth - and by extension the maternal health crisis - must include improvements to working conditions as explained in this Nursing Media Lab analysis.

An easy fix to eliminate disrespectful treatment completely from maternal health services does not exist. It took the Four Seasons, the hotel chain recognized worldwide as the epitome of service and hospitality, the better part of a decade to fully integrate and enshrine into its ethos the golden rule - do unto others as you would have them do unto you - according to famed hotelier and founder of the company, Isadore Sharp. At the very minimum, asking frontline personnel to deliver service with dignity and respect required that their managers first treat employees with dignity and respect. Excellence, Sharp explained, needed to become habitual instead of one-off events. Enabling frontline personnel to focus on pleasing clients demanded that managers focus on pleasing employees. “We treated these frontline people as members of an elite team,” Sharp wrote. The Commonwealth Fund found these same qualities in high performing hospitals where the organizational culture allowed for a superior quality of care to prevail by providing “staff with the right tools to do the job.” For maternal health care providers to focus on listening and responding to the needs of pregnant patients - regardless of how trivial individual maternal health care providers perceive that need to be - the entire organization must be oriented entirely towards ensuring that every patient’s needs are met. The temerity that should be brandished in such situations is reflected in the published text of an address delivered to a group of medical students at Harvard University by New England physician and essayist, Oliver Wendell Holmes, in the 1840s: “there is no tone deep enough for regret, and no voice loud enough for warning. The woman about to become a mother, or with a newborn infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden, or stretches her aching limbs,” he wrote. “God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly or selfishly!” The birthFUND asserts that its mission is more about promising some families an alternative childbirth experience, one that embodies the ideal promoted by Holmes in settings where maternal health care providers treat their patients with dignity and respect rather than endorsing one cadre of maternal health care provider over another. Although the birthFUND may come under scrutiny owing to valid concerns about its ability to scale and sustain its mission, the more pressing question is how or even whether consequential gains - hard won legislative accomplishments at the federal level, in-depth committee reviews of each maternal death in almost all states and quality improvement initiatives implemented in some health facilities - can be translated into the respectful and dignified treatment pregnant patients deserve.

“The woman about to become a mother, or with a newborn infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden, or stretches her aching limbs.”

“I delivered my daughter and had a postpartum hemorrhage, and I lost a lot of blood and they [the midwives] managed it and it was like it never happened,” Phillip said to Welteroth. On the surface, this particular exchange between Phillip and Welteroth seemed striking because Phillip appears to purport a desire to remain oblivious to impending peril after being diagnosed with excessive bleeding, a common and potentially life-threatening childbirth-related complication. Except Welteroth recalled that she, too, had sustained a postpartum hemorrhage during a previous home-birth which was equally managed with such tranquility it left her with the same impression as Phillip’s. “You did not walk away from your experience with birth trauma,” Welteroth said, highlighting something we have heard repeated in numerous anecdotes accompanying stories of pregnancy- and childbirth-related illness and death since the maternal health crisis settled uneasily into the main stream. Thankfully, the postpartum hemorrhage that Welteroth suffered was on the milder end of the spectrum, treated with “lots of IV fluids,” according to Durdin, and unlike those cases in the severe range where the blood loss is so excessive that transfusion of numerous blood products is required and often accompanied by sophisticated surgical interventions and intensive care administered by multidisciplinary specialists. However, to the patient undergoing childbirth, the distinction a maternal health care provider may make between what constitutes a mild or severe complication is less meaningful, Cheryl Tatano Beck argues. To the patient, trauma is trauma. Two patients can undergo the exact same childbirth experience yet emerge with two different perceptions of trauma; what matters is whether they felt safe, protected and had their dignity preserved during treatment. For decades, Dr. Beck, a nurse-midwife and research scientist jointly appointed to the schools of nursing and medicine at the University of Connecticut, has conducted a renowned program of research examining pregnancy-related mood disorders, including childbirth-related trauma. According to Dr. Beck, the imprint of childbirth-related trauma on the brain is triggered when a patient perceives that they have been “systematically stripped of the protective layers of caring.” Researchers estimate that one in 15 patients score above the threshold for diagnosis with childbirth-related post-traumatic stress disorder, which Dr. Beck says, can lead to a host of life-long health problems for both parent and infant stemming from the initial detachment some patients feel after a traumatic childbirth. Worse, maternal health care providers have not responded proportionately to such a high prevalence of pregnancy-related mood disorders; as many as half of obstetricians and gynecologists do not screen their patients for pregnancy-related mood disorders either during pregnancy or after childbirth despite such screening being the standard of practice recommended by the American College of Obstetrics and Gynecology. This means too many patients are allowed to depart from pregnancy and childbirth while suffering a significant degree of psychological or emotional distress without intervention when it is within clinicians’ scope to refer affected patients for appropriate mental health care. Medicaid expansion has at least partially removed lapsed insurance coverage as a barrier for some patients seeking to access mental health services resulting in a small reduction in reports of pregnancy-related mood disorders amongst less privileged patients and modest increases in enrollment for treatment. Still, mental health conditions remain the leading cause of pregnancy-related deaths, almost 80% of which take place between the day of delivery and up to one year afterwards. We should take heed.