1/8/2019 Opinion | Making Pregnancy Safer for Women of Color - The New York Times

FIXES

Making Pregnancy Safer for

Women of Color
By Miriam Zoila Pérez

Feb. 14, 2018

The clinic is unassuming, in an office building just blocks from the revitalized downtown strip in
Winter Garden, Fla., 30 minutes from Orlando. As you head up to the third floor, you might share
the elevator with pregnant women making small talk in Spanish, a grandmother holding a
newborn in a carrier, or a white woman with a baby strapped to her chest in an eco-friendly wrap.

When you enter the Birth Place, a friendly, bilingual receptionist greets you. After you’ve checked
in, you can take a seat on a comfortable couch or chair in the homey waiting room. Jennie Joseph,
the organization’s founder, executive director and a licensed midwife, calls it her “classroom in
disguise.” At any given moment there might be a formal class, socializing among clients, or one-
on-one chats with staff educators.

On its face, Joseph’s prenatal and postpartum clinic might not seem unusual. But when you look
into her statistics, you find something quite rare: Almost all of her patients give birth to healthy,
full-term babies. Again, maybe not surprising until you learn that the majority of them are low-
income African-Americans, Haitians and Latinas.

African-American women in the United States are four times more likely than their white
counterparts to die during pregnancy or childbirth. Their infants are also twice as likely to die in
their first year as white infants, and two to three times more likely to be born premature or
underweight — a sign of insufficient development that can lead to a lifetime of health difficulties.
Native Americans also suffer from higher rates of these problems than whites, as do some groups
of Latinas.

Joseph calls her approach the “JJ Way,” and it differs from many other prenatal care settings in a
few crucial ways. First, she accepts anyone as a patient regardless of ability to pay or health
insurance status.

Second, she sees her ancillary staff — receptionists, medical assistants and educators — not as
her assistants or the people who get the patient ready to see the provider, but as critical parts of
the team that help mothers get to term safely. She will often emphasize that the time her clients

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spend with her staff is more important than the time spent with her or another provider in her
practice.

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Third, she goes to great lengths to ensure that she and her staff treat patients with respect and
consideration. The women come in looking like “deer in headlights,” said Gloribel Parra, a Latina
doula volunteering at Joseph’s clinic. “Once they leave they are breathing easier and have
someone they can go to if they have questions,” she said.

It’s hard to overstate how important the accessibility of Joseph’s model is for the women seeking
her care. “Most of the people who are truly disenfranchised and at risk can’t get past the front
desk anymore,” Joseph said, describing the situation at many other prenatal care settings. “They
may bounce up to your clinic: ʻHey, I need prenatal care.’ ʻWell, have you got money? Have you
got Medicaid?’ ” And if the answer is no, she recounts, the bottom line is “ ʻThen go away.’ ”
Joseph says that clinics that used to bill patients after visits are now requiring cash payment up
front.

The local health department, she said, “has become so short of cash they have to charge you as
well. If you can’t pay, you can’t get started.”

The first tenet of Joseph’s model is offering access. She isn’t helping only women who can’t afford
to pay. She also helps women with pregnancies that other clinics deem too high risk to handles.
And she won’t turn away anyone on the basis of how far along her pregnancy is. “We regularly
deal with tears at the front door,” she said. Patients tell her, “I can’t believe you’re actually going
to help me.”

The other three tenets are connection, education and empowerment. Her staff members are the
main drivers of this, a group carefully chosen for their empathetic approach. “I was 19 when I had
my son — a single black mom with no family support because my parents were mad,” said Trina
Nelson, who has been working with Joseph for 12 years. “I’m 35, so now I’m, like, ʻLet me help
these women because I was there before, I know.’”

Nelson spends much of her time texting and calling clients who can reach her 24/7. “When a
patient of ours says, ʻI’ve got a question,’ I want it answered,” Joseph said. This level of
accessibility is extremely unusual; at many other clinics, you have only a few minutes with your
provider to raise questions and have them answered.

Another element that contributes to Joseph’s effectiveness can be found in a growing body of
research into links between stress, discrimination and maternal health.

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Joseph and others believe those factors contribute to the high rates of maternal illness among
African-American women. “The daily assault that you deal with, just being of color, it’s so lethal,”
she said. “The stress, the judgment, it’s killing our babies.”

David Williams, a Harvard sociologist who pioneered the survey instruments that document the
connection between discrimination and disease, explained that discrimination “leads to a number
of preclinical indicators of health problems,” including high blood pressure and inflammation. “We
have a number of studies that indicate that discrimination is also directly linked to poor health
outcomes,” he said. “The evidence is quite striking.”

By providing easy access to prenatal care, and an environment that insures that women feel
respected, cared for and fully supported, Joseph believes she is creating a buffer against the daily
stress facing her clients. Clinics that make getting care stressful by treating clients with
disrespect or operating on race and gender stereotypes can add a new source of trauma, further
endangering women during the vulnerable time that is pregnancy.

So far, Joseph’s outcomes for the 600 or so women she sees annually have been impressive. A
recent outside evaluation of her work funded by the West Orange Health Care District found
preterm birth and low-infant birth weight rates among her patients significantly lower than rates
in other settings. Joseph’s clients of African descent were almost 40 percent less likely than
women of a similar race throughout the nation to have a preterm labor or a child with a low birth
weight.

These findings are consistent with two earlier outside evaluations of Joseph’s work, and further
illustrate that her model is an unusual bright spot for a problem that is worsening in most areas,
not improving.

But while Joseph’s model is low-cost and accessible, there are certainly hurdles to replicating it.
Joseph spends countless hours trying to get Florida Medicaid to enroll her pregnant clients, and
then many more hours chasing down the $50 per appointment fee that Medicaid will pay. Her
financial model is lean — a staff made up of midwives and medical assistants means the salaries
are more manageable.

Joseph would love to hire a full-time nurse practitioner, but doesn’t have the money. She’s had
some success raising funds through her associated nonprofit, but those are generally restricted to
programs, not salaries. She often deals with a lack of cash and burnout.

Her approach is also not a magic bullet for larger systemic issues facing poor women and women
of color. While Joseph has made major strides, her clients’ difficulties don’t begin with illness and
disease during pregnancy, and they certainly don’t stop there.

A 27-year-old African-American client whose child had come through pregnancy and birth
healthy told me that she was now struggling financially. A medical complication after birth had
caused a longer than expected time away from her job, and now she wasn’t sure if she could cover
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her rent and food bills. A clinic employee sent her off with diapers, formula and phone numbers
for food banks, but none of the mother’s larger problems would be solved by these stopgap
measures.

Other providers have tried to use Joseph’s model, but she isn’t sure if they are applying it
faithfully enough to produce the same results. While her method doesn’t depend on expensive
medicine or technology, it does require fundamental shifts in the approach to health care. They
include valuing the role of the staff from the front desk to the head practitioner, and approaching
women who often suffer implicit bias with respect and a belief that they can achieve a healthy
pregnancy despite the odds against them.

But of course, the potential payoffs of Joseph’s model — the provision not only of respectful care
to marginalized women but also a path to ameliorating a longstanding and difficult-to-address
public health problem across the nation — are worth striving for.

Miriam Zoila Pérez is the author of “The Radical Doula Guide: A Political Primer for Full Spectrum Pregnancy and Childbirth
Support,” and a columnist for Colorlines.

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