Your BIRTH Partners

Reflecting on State & Future of Birth Care

September 14, 2020 Season 2 Episode 2
Your BIRTH Partners
Reflecting on State & Future of Birth Care
Chapters
Your BIRTH Partners
Reflecting on State & Future of Birth Care
Sep 14, 2020 Season 2 Episode 2

In this episode we had the opportunity to welcome Dr Mimi Niles, PhD, CNM, MPH in for a lengthy conversation about the state of birth care.  We're talking about what's missing at present, the improvements we need to make with midwifery, nursing, and medical education to put person-centered care and a health equity lens at the forefront, practice changes to increase client comfort and autonomy, and what we hope for the future!

Support the show (https://www.paypal.me/yourbirthpartners)

Show Notes Transcript

In this episode we had the opportunity to welcome Dr Mimi Niles, PhD, CNM, MPH in for a lengthy conversation about the state of birth care.  We're talking about what's missing at present, the improvements we need to make with midwifery, nursing, and medical education to put person-centered care and a health equity lens at the forefront, practice changes to increase client comfort and autonomy, and what we hope for the future!

Support the show (https://www.paypal.me/yourbirthpartners)

Margaret Runyon :

Welcome to Your BIRTH Partners. We're here to break down barriers and cultivate community as we discuss issues that impact pregnancy, birth and postpartum. We welcome you no matter what your background is, and are so glad we're here to learn together. This week, I have the pleasure of continuing a conversation with Dr. Mimi Niles. For those of you caught our last episode, you have already had a glimpse into the clarity and brilliance that Mimi brings to talking about issues surrounding perinatal healthcare. So I am really excited to share more with you about this conversation; we talked about so much of what is impacting really the state of prenatal health care. We talked about respecting individual choices and what that looks like with the language we use and how do we advocate for those who are in our care. We talked about birth pro education, where we are missing the mark and some steps we need to do to move forward as those of us who are experienced birth pros and those who are just starting out. And we talked about really trying to change the landscape, recognizing the racism that's been inherent in our system, and actively taking steps forward to create a system that actually has equity at its base. So I am just delighted to share this whole conversation with you. And because I am human, unfortunately, we did have a little bit of a technical snafu. And so Mimi was very gracious to allow us to kind of restart the interview after missing the first 10 minutes or so. So very grateful for for her for catching that we weren't recording and letting us start over so you'll catch that at the beginning of the episode. Thanks so much for being here. Onto the show! Now that we've been chatting forever, let me formally introduce you.

Dr Mimi Niles :

Okay, great.

Margaret Runyon :

So I am super excited to have Dr. Mimi Niles on here to chat with us about birth care and advocacy and what it looks like for her in her practice as a midwife, as you know, a researcher with the birthplace lab as a, you know, nursing school professor, and really as a voice for midwives, and for birthing people to really kind of step into what they want for their birth and for all of us to be a little bit more aware of it. So I have been following Dr. Niles work for, you know, this year and just really been blown away by the nuance that she brings to healthcare and to thinking about birth, and the way that we provide prenatal health care. And so I am super excited to have her on here to chat with us.

Dr Mimi Niles :

Oh, thanks, Maggie. We've been chatting but didn't capture everything.

Margaret Runyon :

Yeah, so we've been chatting and had a technical difficulty, as well happen. And so we'll loop you all into the conversation now that we're all recording. Yeah. So Mimi and I were talking about, you know, really how we provide care to people and you know what that looks like? And how do we see what's happening in someone else's world and really kind of step into that in a place of from respect and a place of humility to really be receptive to what they need. So I'll let you take it from from there.

Dr Mimi Niles :

Yeah, I mean, I was we were just talking about something I've changed. I mean, it's just to truly jump into this over the changed in my practice. I've been practicing for going on 11 years and attended hundreds and hundreds of births. You know, I mean, that you know, as midwives we call it, the catch and catching a baby and have been really conscious lately of, you know, as that human emerges, just having the first hands at that child feels, wanting them to be the laboring parents' hands or the support parents' hands or the support grandma or whoever it is, that is wanting to be in that role. I've been really trying to consciously support that and really sort of advocate for that because i think it's more than just a moment of like a really cool thing to do, you know, but I think it's a symbolic gesture of that we there in the labor room, the professionals in the labor room are really just kind of guardians of the process, the actual labor and the work happening is is in that laboring parent's, that laboring mother, and I-it's so important, you know, like when people say to me, oh, you delivered my child or if another provider says, I delivered 500 babies or something like that. It really is like a screech moment for me because I think even that language of taking away that work that's being done is really super problematic, and it's our language matters, you know, and I think that's why midwives have claimed this kind of like we catch babies or we attend births or really trying to be conscious around this like delivery idea or doing deliveries. You know, my cousin had a baby and it was very precipitous. So his partner ended up having the baby at home. And so he texted me and he said, you'd be so proud of me because I delivered the baby, you know, and I thought, No, you didn't know your wife did all the work.

Margaret Runyon :

[laughter] I support you, but... That language is really important as someone who you know, most of my training has been in hospital settings. Obviously, delivery is part of you know, the vernacular, but it's something that over the last couple years, I've really tried to, it slips in sometimes, but I really tried to take it out of the vocabulary, especially when, you know, we're talking to to birthing parents about what they're doing because absolutely, they are the only people who deliver their baby into the world no matter how they come out. And I do think returning that, really just that power to them, and I think you know, something that you could we touched on earlier is that, that feeling of like, respect for the family, and how do you want to speak just a little bit to like that background that you have in kind of like community family nursing and how that plays into it?

Dr Mimi Niles :

Sure, sure. So I was telling Maggie that I went into nursing as a pathway to midwifery. So I always knew that I wanted to be a midwife. And if you're in the birth world, you know that there are multiple paths, pathways to midwifery in the US, which could be a whole other episode, but so my pathway was the CNM pathway. And when I graduated nursing school, I remember everybody was telling me you have to do med surg, you have to do med surg, and I thought, God willing, I will avoid med surg at all because I knew that I wanted to do ultimately do birth work. And so it felt like what would give me the skills that would sort of build towards that dream of being a birth worker and the first job that I got offered was visiting nurse, Community Health Nurse here in New York City. And everybody told me I was crazy that I, you know, I would be in homes alone, and I wouldn't know what I was doing. Because there's no one; there's no one to ask, right when you're trying to figure something out.

Margaret Runyon :

A different safety net...

Dr Mimi Niles :

Yeah, yeah. And you know, you might call your nursing director and they might not be on the phone, or you might call the physician and you might not hear for them for for more, you know, for days when you need an immediate, immediate answer. But it was the most humbling, most enriching even now, like professional work training experience I've ever had because it sort of create this really deep sense of humility because you're entering somebody's home. You're kind of getting entree into their family unit and into their culture that's just like you knock on the door, the door opens in this just this whole world that you have to very quickly assess and understand comes into your view. And then you have to, I think a good visiting nurse or a good community health nurse or any good nurse provider, like finds a way to humble themselves really, really, really quickly. But nothing will do that, like home care, because you don't know really what you're entering. It could be so many scenarios that could happen. But I think those are the skills that I wanted as a midwife, because even though I've worked for 11 years in a very, very big hospital system, I still open that door of that labor room, and that is the same sort of spirit or energy I bring in sort of a complete humility of, I don't know, this family system, I don't know their history, I mean, you know, their clinical history, but that's very different than as you know, like you don't know the internal family dynamics or, you know, the very personal intimate histories and I think that's what I struggle with as a birth provider is that we've, we've like, we have thrown all of that out already. We expect all of that to be thrown out of the birth experience. But really, if you really just watch your birth happens, all of those things are really magnified in the birth experience all the the love and the tensions and the histories of families and partnerships and parents and grandparents and sisters and auntie's, and it's all like, it's just all there. You know, if you're in the like the rawness of the birth experience. Yeah. I don't understand how women let us have let us get away with this as institution based providers of saying, telling them that none of this matters, you know, your blood pressure matters, your diagnostics matter. Your FH matters, your contraction pattern matters, but we don't really care if you don't have such a good relationship with your mom and she's in the room with you. And to me that that is like another vital sign that that absolutely matters, you know, or that you have, you know, you're a single mom now or you're not with the father of the child or the other parent of the child anymore, that matters, right? That matters to me.

Margaret Runyon :

Yeah, I mean, so much. Oh, yeah, in health any time, but especially going through the transfermation that birth brings with it and welcoming a new soul into your family. What, who is your family? You know, I think we obviously in the US, we've, you know, we've created this whatever this you know, box of this, you know, happily married, you know, cisgender white heterosexual couple, and regrettably, that has dictated so much of how we based care off of, and while that might be a reality for many birthing people in our country, it is not the reality for all of them. And I think in our big institutions, we just have a really hard time moving past that and really accepting that like there is validity in all of the different ways that families come together, but it also means we need to change what we're doing. Like, we can't just say like, "Oh, that's cool, you're doing a different way, I'm gonna keep doing it the same way, I always do it for everyone." There's a huge disconnect there. And I do think the, that background that you have in, in home nursing probably really helped to solidify that piece of it for you. And I was saying, you know, I wish, I wish all of us in any healthcare field, no matter what you're going into, as you know, as a nurse, as a physician, as a midwife, that we have that chance to have time in community, time where we really see that the job we have is one piece of this bigger puzzle going on in someone's life and really respect and kind of be humbled to that because I think part of the, you know, so many advocates for birth, speak to, you know, homebirth is kind of this, like, almost this pinnacle, you know, kind of piece of it. And I think the reason that that happens is because of kind of traditional homebrew midwifery model really is person centered and you are in their in their space. So you can't help but tune into all of that and encourage them to just be themselves more. I think there is a piece of it that when we people come to the hospital to give birth to their babies, they come into our turf, and we lose sight of who is still, like you said, when you open the door that is still this is their space, it is their body. They're the ones who are giving birth. And, you know, I don't think that home birth midwifery is is you know, right for everyone. But I do feel like obviously, that what we what is brought into that model of care is what we need to bring more of into hospital based birth care, because it has to still be there space, it has to still be there has to be all that attention to what makes them themselves.

Dr Mimi Niles :

Yeah, yeah.

Margaret Runyon :

Not what I want to do because I did that way my birth or is the way I've done it 100 times before.

Dr Mimi Niles :

Right, right. I mean, I think the issue though is that people who choose homebirth. And even providers who choose to be homebirth providers are saying this institution does not serve us and it does not serve our needs. So we're stepping out of the institution. And I know people that say we need to bring that model to institutional care. But I think the, the way institutions were designed, and I know this is hard for people to listen to, it was designed actually to exclude the person centered model, and it was designed to exclude sort of shaping your care to match what the person needs. It was designed in sort of a factory model type ways so that everybody gets the same thing. Right. And so we have fetal heart rate monitors. Everybody's on a fetal heart rate monitors so that a nurse can watch multiple people at the same time, right and so what you've done is a lot that technology has actually doesn't allow for us to return to a person centered model, because now the technology has sort of surpassed sort of the human capacity in a way. And if like, if a nurse comes up to me and says, Well, you know, I just, I don't feel right, about something or a little bit too much bleeding or a little bit, you know, something, you know, it's not picking it up on the monitor, but I'm hearing these little dips, and you know, like, things like that, that matters to me more than, like, I'm not just going to look at the tracing and say, "well, I'll don't see anything on the tracing." I think the tracing also was designed to provide legal protections, all these other types of things. So I don't have as much faith in the institution, as maybe other people do, because I took an institutional job thinking I was going to be sort of a, you know, I was going to do midwifery from the inside. And it's really hard, you know, and I'm, it's really disruptive to one's sort of spiritual grounding in the work. And that's where I am now with my research is sort of looking at how do midwives within the system, how and what do they do or not do to kind of preserve what we call the ethos of their model, like what do you do to preserve the ethos model of midwifery when a homebirth midwife might see four people tops in a four or five people tops in a clinic day, or their clinic visit day? I'm seeing 25 to, you know, sometimes I've 31 people my template. So what can I do with this model? To preserve some of that ethos because it's, if it's just about time, I'm not gonna be able to do it, right because I might I have like 10 minute blocks or 15 minute block. But my theory is there's got to be more than time, there is something about how we relate to the people that we take care of. And that whether midwives within a system because a lot of us do, 98% of us work in a hospital system. What are we doing to? Are we able to translate anything of our model which was more designed to be delivered in homes and birth centers? What can, what are we doing in the institution because I suspect two things I suspect, we are just functioning as physicians in a way without the surgical skills, although some do first assist, or we are really struggling in that system, and we're getting burnt out and torn up and because we're, we're fighting, like we said earlier, other sort of ideologies of nursing ideology or physician ideology, and there's not a lot of alignment. You know, I can tell you how many nurses I meet in nursing school or my students who have never heard of midwifery. You know, I think if a nurse hasn't heard of midwifery, then we have we're failing right here, totally failing.

Margaret Runyon :

How is anyone else who wants to know that it's even an option? Right? Yeah, that is such an important distinction. Because Yeah. As someone who's worked predominantly in, like, in hospitals and health care institutions, I totally went into it in that same feeling of like, right. "So this is how you change things, right? Because you get in there, and you're just going to be able to like, kind of change things from the inside out." It's, it is so much more complicated than that. And like you made such a good point about just the fact that like, they, they were intentionally designed to do the opposite. And so that is something that as you know, as providers and you know, birth professionals who work within hospital settings, I think it's that's just a really important reminder to keep kind of like bringing to the forefront when we're interacting with institutional policies when we're having these back and forth, is to have context for that. And I also think, like you just did and saying that out loud, like you're having issues on your unit, you're discussing a policy just saying like, "hey, timeout, do we realize where this is stemming from? And is that how we still want to keep going? Is that the path we want to continue on? Or are we actually ready to do something very different?" And I think often the answer is, "no, we're not ready."

Dr Mimi Niles :

Yeah. Yeah.

Margaret Runyon :

But, uh, you know, I think as we continue to have this conversation, it does get, you know, it gets closer to having that I think we know what I was saying earlier, you're the article that you and you know, some of your colleagues had really written about the pandemic. And because obviously, this has just been, like, everything under the magnifying glass in terms of issues that are present in our society at large, in healthcare in particular, and really in birth care, and how do we really actually view the rights of birthing people and who is in charge of their care, who gets to dictate it? And you know, you all had written really beautifully about kind of balancing out these concerns for birthing people and for birth professionals and really took a just a nuanced look at What it means to provide ethical care that is equitable in any in a good day, and then also in really, really hard days when things are challenging. And so I don't know, if you want to, you know, to speak to how has, you know, working through this pandemic, especially like, what do you feel like you've kind of gained, particularly during this time? And it doesn't have to, it doesn't have to be positive. It might be a deep sense of sadness about the system. And that's very understandable. But, you know...

Dr Mimi Niles :

Yeah, there's a lot. Yeah, there's a lot I think, I think I'm still processing it. Because I'm in New York City. We were the epicenter of the pandemic and the hospital where I service was one of the, like, worst hit communities to have this experience. And, you know, New York City experienced a few maternal deaths during COVID as well and so it's really been a lot have self reflection, I think, as a midwife, as a New Yorker, as a researcher and just stepping into a role where I don't want to be just to the ivory tower researcher, I really want my work to be feed into advocacy spaces and feed into sort of activist agendas. Otherwise, I feel like you know, it's been made clear to me that my work, I want to be on my deathbed and to think I helped to change midwifery, maternity care, perinatal care, at least in my little maybe Brooklyn neighborhood but in in America, because it's not working for anybody. And that was sort of the goal of that paper to say this system actually is failing all of us. It's not just, I mean, mostly failing Black families and Black women and Black mothers that is clear, if COVID has not made that clear then that should be crystal clear, and it's failing the systems that predominantly take care of Black families because that's the system that I work in and and really what I'm beginning to understand that I can be as loving and kind and compassionate and humble and educated and woke or whatever you know as I can try to be and, but the system is going to, it's not designed to be loving. The system is never going to love you, yoou know, it's really there to get paid. And, you know, this kind of like base commitment of doing no harm to me is not enough. You know, it just not enough. I mean, to me, I, you know, we talk a lot about physicians doing no harm. And I think if that's the bar, like that's the lowest bar itcould be, right? It's basically saying, we're not gonna hurt you, we're not going to kill you. But we're not even doing a good job of that. Right?

Margaret Runyon :

We're not even meeting that bar very often, and it's a very low bar.

Dr Mimi Niles :

Yeah, so I want the bar even higher. I want the bar to be, you're gonna walk out of our system and you're going to feel like a more full person, you're going to feel more whole, you're going to feel more healed, instead of like, at least, you know, I don't want people to walk out of my care and say, I feel more broken, I feel more hurt, I feel more harmed. I can do that on my one to one interactions. But if the system is forcing me to see 30 people a day, and the system is forcing the person getting care to only have my time for 10 to 15 minutes. Because it's a medicare/medicaid predominant system. And yeah, those systems are really, really struggling with being defunded, or being chronically underfunded. You know, it's very complex. So it's, it's more, I don't want to minimize maternal death. I just want to say that, it with the systems we have in place, I don't see improvements without a radical shift in how those systems function in communities that have been underfunded in every single part of their lives. In terms of their ability to access safe, affordable, stable housing and food sources for their children and great schools for their kids and things that I take for granted for my own kids, you know, and clean water, you know, that we don't like there's still plenty of communities and we have dirty water, you know, and so if we can't guarantee those things to the people we take care of, and then we think that when they're in the hospital bed, none of that matters is really I think something that nurses and midwives and physicians, we're getting duped in schools now, I feel because we think that if they have a good clinical care episode, it'll somehow magically resolve their health problems. And that is, that is just, it's bullshit. It's not true. You know, they're walking in with the whole generations on their shoulders. We all are. And they're walking out with that, too, you know, and so, yes, the healthcare experience is important, but it's not everything, you know? And are you talking to your families about like, what kind of home are you going back to? Do you have the kind of support that you need? Do you? You know, do you have clean water? Do you have employment or have you been unemployed? What does this kind of what does being a new parent gonna look like for you? Because just because you walk out of there and you have a baby in your arms and you didn't die. Again, to me, that's the lowest bar that you can get.

Margaret Runyon :

Right? Absolutely. I mean, I think and we've talked, you know, before on the show, like post partum, that whole entire period is so just ignored, like, just flat out ignored. And I think as, you know, as as a nurse, like even when you're, you're going through it, and you're very focused on the birth and right and even if you meet that really low bar of like, yes, you and the baby are both alive, and I'm sending you home. Like we don't have enough; there's not enough training, there's not enough practice and how to skillfully really assess how is that going to go and provide resources and support in a way that doesn't demean or criminalize parents for not perhaps having every single duck in a row when they showed up to the hospital. And that's a huge, a huge missing piece and a huge piece of why, you know, the high rate of, you know, maternal death in that first year postpartum due to mental health issues because we're not looking into that. We're not actually assessing what people are really going through. And that's and like you said, that's if they actually even make it, you know, out of the hospital. So there's just there's so many layers to where we need to increase the support we give and a huge piece of that comes into us as birth professionals, as healthcare providers, being willing to, like have those conversations and learn how to how to talk to someone about their home environment in ways that are comfortable and are not judgmental. And that do not have this, you know, I think, unfortunately, so many times when people are in difficult situations, there's just always this threat, the you know, the CPS threat, the threat of who else is going to have to get involved, instead of being able to provide resources in a way that really feel congruent to what the person wants, and that is a huge issue.

Dr Mimi Niles :

Yeah, it's such a big issue. And I think, you know, I mean, the other thing that makes me that COVID has made me realize are deeper is that the hospital systems have not put in the effort, for the most part, I'm sure there are exceptions to this. But have we become part of the community? Have we truly become a community member, a community stakeholder? Or are we just an institution or a building that has been plopped into the middle of a community? That doesn't that's not enough work to call yourself a community member? Right. So the bridges between what the community needs and what the hospital can offer? They haven't really we haven't invested in the time or research or thinking around that how many of us work in the communities that we serve? I don't know. I wonder about that. How many nurses and physicians and midwives and admins and everything do you actually work in those neighborhoods? Mt guess is depending on where you are in the pay scale, the lower you are on that pay scale, yes, you probably are of that community. And the higher you are, you may or may not be known depending on I'm talking about the community, you know, sort of the underfunded public health communities.

Margaret Runyon :

I would imagine, like in urban environments...

Dr Mimi Niles :

Yeah. And I think that's really problematic. I mean, I we have to talk about the fact that midwifery is, you know, over 90%, a white work woman workforce. That is what it is. And that has some deeply racist, complicated racist roots. You know, nursing is the same, you know, I don't think I don't know how much nursing talks about it. Yeah, I'm just more tuned into the midwifery conversation, but like, we have a very deeply racist history.

Margaret Runyon :

Yeah. I think ufortunately, at least in my experience, it is very, not acknowledged. I think, I think it started I am definitely seeing changes in you know, the educators I know who I'm talking to, especially in light of just everything that's happened this year. I think there has been a a way late wake up call that we really need to change the way we are, you know, conducting nursing education, but that is not crossing all of these boundaries. And not everyone; there are plenty people who still don't want to acknowledge that because I think they feel if we just if you don't say it, it doesn't, you don't acknowledge it, it's not real, it's not happening. And I think it's very easy, and I say this as a white woman, it's very easy to fall into the idea of just like, yep, ignore the negative just keep, keep going along and just have this very narrow view of what it looks like and what it what it meant to you to become a nurse. And this, this idea of like, right, you know, Florence Nightingale, the only nurse who's ever talked about kind of a thing, and there are so many more complicated parts of our history, and, you know, tons in terms of health research and how we've carried ourselves out and, and the way that we have always applied policies, and how, you know, bias both implicit and very explicit, has impacted care and, you know, racism has been has been rife throughout healthcare. Yeah. Because it has been rife throughout our throughout our country, because it is how our systems have been made.

Dr Mimi Niles :

Right. Right.

Margaret Runyon :

And so I think, you know, absolutely as you know, as birth professionals, we need to be really tuned into that and and like and like that we'd have to keep, we have to keep talking about it and then putting action in place. It's not enough to just acknowledge that it happens. And I think that's what unfortunately, we saw so much and kind of the fear over the summer is that a lot of places I saw acknowledge, I did see lots of schools of nursing and you know, midwifery organizations and doula groups and you know, physicians saying like, "yes, racism is wrong. We need to do you know, something about this," but then...there's the void of what that actually means. And so I think it's, you know, it's obviously we need to keep continuing to work through and being really conscious of each of the interactions we have with everyone.

Dr Mimi Niles :

Because it I think it needs this is the root of all the evils I think, is the real power of redistribution. And who is willing to do that? You know, I like I struggle lot with the fact that only 10% of the maternity care workforce are midwives in the US. When you compare us to other sort of high income, high resource countries, that pyramid is reversed, right? Where most of their primary maternity care providers are midwives. And the physicians are really thought of as the specialists. And we have flipped that proportion. So that OBs who are surgical technicians in my mind, you have become sort of the generalist or the laborist and it doesn't make sense because they don't view birth in general as sort of a normal physiologic process. They're trained to, to discover pathology and to specialize, and to do surgery and to look for what's wrong, versus midwives who are actually deeply trained and to look at the physiology of birth. And in that training, we learn when it's not going, you know, right. We're like, oh, something's not right. Something's going off here because for most of humanity, the human body has been able to birth people. Doesn't matter where you are, there's not we know there's no biologic difference right? Between birthing bodies, so what's happening here and what's happening in Bangladesh should be that it's there's really no difference right? And so I think we need to really there has to be a reckoning and a truth telling and a reckoning around how is powered distributed in health care, both internally and externally. And we know that power and health care is physicians on top, and everything else on the bottom and until that power paradigm shifts. I, you know, I don't mean to be a pessimist, but I don't see a lot changing in maternity care because the power paradigm has to shift and we have to say "most people will have bormal physiologic process if we if we support them, and if we create the right environment. Most people will do that. And for those that don't, how do we continue to support a process even if some pathology gets introduced? I'm of the mindset is you can still keep it normal. Yeah. I mean, yeah, I'm still it can still be special and sacred, you could still have family-centered cesarean, I mean, there's, there's things that we can do to make this process loving and humane and compassionate...even if you have preeclampsia, even if you have diabetes, even if you you know, whatever other comorbid condition rises up. We can still we can and still should be doing it, and I challenge nurses and midwives and physicians, particularly female identified of us, that being nice is that is not the end goal either. To me, that's the bar, the bottom of the bar. And I said I've met a lot of nurses and midwives who are just like, "well, I treat all my patients the same and I'm really, really nice to my patients," and it's just "It's okay. And?" you know?

Margaret Runyon :

It's just not enough.

Dr Mimi Niles :

Yeah, yeah.

Margaret Runyon :

Yeah, I think we've been, you know, especially in this country just because people think we're a wealthy nation, we theoretically have access to all these brilliant minds. We've kind of skated on our laurels about that, like, of course, we have great healthcare, like, of course, birth care is going well here. No, it has not, it has gotten, you know, worse. It's twice as bad as when my mother had me; the maternal mortality rate has doubled, you know, since then in those, you know, 30 odd years from that's not and that's not okay. And we have hidden that from view. In the way that then people feel like that there is just this, this baseline is like, well, if you're just like, keep doing your job, right, and that's fine. Well, no, it hasn't been working. It's not fine. It's not okay. And there is a huge, you know, shift. I had the chance to talk briefly with Dr. Neel Shah, about this topic as well. And one of the things he said is that, you know, as a physician, he is really trying to be increasingly mindful of where there are those opportunities to cede power, you know, whether that's in, in the birth room and in, in speaking engagements in, you know, passing the mic to other people to share those other voices that haven't had a chance that, you know, who hasn't been able to really dominate the conversation in the same way. And I do think that's, that is gonna have to happen, but like you said, it's hard because it means that people who have power have to give it up, and that's, that's challenging for anyone's ego, to let go of something that you had. But you know, it's a process.

Dr Mimi Niles :

And it's just super, it's, it's, I mean, I, I get uncomfortable about it, too, especially as a woman of color. I feel like a little bit of power. I have the thought of kind of, that I've worked so hard for whenever that power is I don't even think I can put it in a box. But, you know, just the fact that you've contacted me, to me, it feels like there's a power in that right.

Margaret Runyon :

Yeah, yeah.

Dr Mimi Niles :

So what am I going to do to use that? And I do think that what I'm learning too, and I want to speak directly into it, whether you use it or not, is that there's something about how black women lead, that I am learning from, that I am in, in absolute reverence of because despite everything that this American system and world keeps telling them, they continue to sort of push through in this space and say, "Listen, if you make it better for the most marginalized," right, this is Black Feminism 101, "If you make it better for the most marginalized, it will get better for everybody."

Margaret Runyon :

Every one rises.

Dr Mimi Niles :

Yeah, because what we don't talk about with with maternal health, is that it's it is yes, it's getting worse. But the reason it's getting worse is because the gap is getting bigger. That means white women are doing so much better. And they've left people who are marginalized are still doing poorly, right? So it's not just just they're doing poorly and everybody is. It's that the white women are doing so so much better. So we know that it's possible.

Margaret Runyon :

It's an even bigger divide.

Dr Mimi Niles :

Yeah, we know that we can we have the capacity to do it.

Margaret Runyon :

So it's not that childbirth is so inherently dangerous that we can't do better.

Dr Mimi Niles :

Right. Right. And it's it is a gap, it's a widening gap. It's not just one side, the marginal side is falling away from the center; it's that the privilege side is is moving way past the center to. And so we think we need to talk about it. White women need to talk about that, like we are doing so much better. What are we going to do for our Black and brown sisters to make it better for them? Because now we have that privilege resource we are, you know, we have that resource. What are we going to do with it? You know, I think that's, I don't I don't know if enough white women or white nurses or white midwives are having that conversation and say, what are we going to do it? Yes, power ceding is important. But also what are we going to do with this resource that we have to kind of draw people back into into the center who've reallly falling away. And I'm not, I'm not asking for white people to do that for me, but I'm just curious as to, are White women talking about that?

Margaret Runyon :

No, it's necessary. I mean, I will say, with relative confidence that not enough of us are talking about it, because if enough of us were talking about it and taking action, we wouldn't be right here, you know? And so I do think it's something that it's something that I again, as a white woman, like I am trying to stay just increasingly conscious of it and having those conversations with with different people, people from different walks of my different places that my my path crosses with people. Because again, it's there is that the comfort when you don't experience something that you can just turn a blind eye to it and ignore it. And especially in like you said, in, in birth care, that is literally causing only more and more and more harm to everyone who is not White. And that's unacceptable, on a human on an ethical level, to let that continue.

Dr Mimi Niles :

At the same time, right because it's never to me, either/or. Is that the principles of reproductive justice apply to White women to right? Because if your autonomy is being stripped, your capacity to choose things for yourself is being stripped, and you're blindly following whatever your provider tells you. Your justice, where is your sense of justice about what's happening in your own body? And your own the sovereignty of your body? Right? Yes. I think that's also simultaneously happening where that's, you know, I've taken care of, I've talked to people in the city, you know, people are like, "Oh, can you talk to my friend, you know, your midwife? Can you help them?" and they're, like, some executive at Google. And you ask them about their birth experience, and they're like, "Oh, my God, I don't know. It just, you know, just, I just use the person who is giving me my pap smears." I didn't really research who the provider was going to be of this immensely intimate experience. But I've spent two hours researching strollers, you know what I mean? So it's sort of like, what are we all doing here? We're all in this sort of physical process is happening, and how have we all? How have we let this conversations fall so far out of sort of feminist discourse and like radical feminist discourse that we've been left in the dust? You know, we've really been left in the dust in terms of like, no, this is my body, my body mind choice. Like that's, that's the same. The abortion slogan should apply to us to my body. My choice, you know?

Margaret Runyon :

Yeah, I mean, obviously, all of like, reproductive justice. It is it is all of it. And I do think again, I think we saw it unfortunately; we saw it when white women were working to get the right to vote for them and not for all women. We saw it when you know, really, you know, in the 60s,70s. As you know, regret rates really hit off and again, it was very focused on the experience that you know, white women wanted from it that we are not being inclusive. And we're not, we're not seeing often enough the experiences of people outside of our own, whatever that little microscopic part of our world is to see what people need. It absolutely leaves all of this behind. No one of us, all of us, you know, it really is. And like you said, I mean it is it's Black Feminism 101. And it's, it's hard that that's not just like, being human one on one that like if we're all doing, we're all doing well.

Dr Mimi Niles :

And shouldn't we be taught that in nursing school to me. Yes. Like that's to me semester one. You need to be doing like, like, social theory and critical race theory, health disparities and health equity. And we're not learning about those things. We're really we're like they're reinforcing. Like the stupid stuff from cultural competencies still being reinforced. And it's so frustrating to be in front of a group of 19 year olds or 20 year olds who are like, "I want to help people," which is so beautiful, to be 20. And to know that about yourself is a beautiful thing. And then to fail them when you ask them what's a risk factor for preeclampsia and they say "being Black," and there's absolutely no, no other kind of critical thinking around that. I want to cry every time it happens, I feel like a failure. And I feel like I want to cry because that means whoever taught them before did not teach them what it means to be in America living in a Black body. It's not about you being Black in the color phenotype of your skin. It's about everything that comes with the history, and the current reality of being Black in America means you can still get choked to death, Black people are overrepresented in the prison system and under represented in the legislative system, and the educational system, and the healthcare system. And you know, like all those things that I want my students, I want them to be able to, you know, their hope to have their PhD in it, but to be intelligently be able to say, the experience of racism, anti black racism is what the risk factor is for preeclampsia. Yeah; I'd be much more happy with that response.

Margaret Runyon :

Yes, I think, you know, the conversations that's been happening and you know, "Racism, not race" that I feel like, you know, Dr. Joia Crear-Perry, she's said over and over again and you know, several webinars and things that I've heard, like, that distinction is huge. And I'm so glad that we're stating it so explicitly now, so that it can hopefully help. Because I know, I'm speaking for myself, I went to, theoretically an excellent nursing program, and I learned a ton there, and I'm very grateful the experience I had, but I was a years into practice as a nurse before I really understood health equity as a concept; why is that? That should not have been that way that absolutely should be covered in those first couple years in nursing school when you're just getting a baseline for how that works. Like we just didn't have that context; it wasn't there. And, you know, obviously we all grow and you know, deepen & mature in our practice as well. So no, none of us come out as experts; are we ever experts even? But no, you know, there is that piece of at least having a baseline knowledge and understanding and some of those concepts & terms we'll use and to apply when you come across a situation that you realize like "whoop, hang on." Like, the red light is flashing something is up here. And you're able to then look into that a little bit more and ask questions and figure out plans and have that knowledge and that language around it to discuss when other people. That's a big difference. I can certainly look back at times in my career where I did not have the knowledge or the language to say like, "Oh, actually the issue right now, I think, yes, is that we're being racist," and it would have been really helpful if I had had the confidence, or, you know, or just know how to realize like, "hey, actually, maybe if I could just call out that like, actually, guys, that's the issue right now that I think we're really viewing this from the wrong context."

Dr Mimi Niles :

Yeah.

Margaret Runyon :

And how many lives that could have potentially changed or at least that situation could have changed? If all of us were more educated on that. Yeah. I mean, to me, that goes directly back to the power of conversation. Can a nursing student, some will, you'll have the outliers, can they really do that? Or can you be in a conversation with a physician in in a debrief or case review and be that person as like a first year midwife, you know, it would be really, really hard compared to who I am now, when I say "I'm Dr. Mimi Niles and this is what I know." But it took a lot of work for me to, to to get there and it does; it shouldn't be that way. That's how I feel. And I know we got to wrap it up, but I feel like doing this work, it should always feel like a privilege. It should always feel like a privilege. I mean, you know, my, my midwifery director always says like, she's very, very raw, very, very explicit, and says, like, "people are looking at your vagina, who do you want to look at your vagina?", you know, like, that is such an intimate experience. And we have stripped like I said in the beginning, we have stripped it of all of its intimacy, and all of its sanctity and all of its humility, right? So we go in there and we lift the sheets and we, you know, all the bullshit stuff that we do is about power. It is totally about power to me. I mean, that's the fundamental pulsing heart of what happens in every single not just a labor room. But the labor floor and the unit and the hospital and the you know, so it, you know, I really want people to be thinking about sort of the ecology of nursing. That it's not just, because we think it is it is interpersonal and the relational aspect of our work is so important, it's the beating heart of our work, but it's an ecology, right? So there's the interpersonal, and then there's the institution, and then there's the community, and then there's the town you live in, and then there's the state you live in, in the country, in the world. I mean, so you have to keep expanding out your consciousness around what does your work mean, as an interdependent work in a complex, multi layered multifaceted system, that it's not just you be nice to somebody who's going to, you know, I don't know cure all the ills of racism. No. But do you, can you bring that consciousness to your interaction with someone you know, and know like you said, it is going to be a muscle that you, it's like going to the gym, you're gonna have to keep working out, it's never going to be a done deal. And it is going to require people with power, historical power to do more work. And are they willing to do it? I don't know. I don't think so. But that's, you know, what is the system going to demand of them? I know as a professor, I'm going to demand something else with my students. Yes. You know, I don't care. I mean, I want you to pass your NCLEX but I also want you to be able to critically engage, what racist health care looks like because that's the kind of health care we have right now. Oh, my gosh, yeah. I mean, there's so much in just how we do nursing and midwifery and medical education that is so, ike so much of education in this country. That's so built on a test that we're hoping is measurement we think it is, and it, it's not, it's not doing, it's not doing the job we need it to do.

Dr Mimi Niles :

And it's going to reinforce people who have resource right because you can get a tutor and you can take take Kaplan and you can, you know, maybe your parents are professors and they can you know, like when I'm helping my teenagers I have to really tell them you guys are, you know, this is such a privilege for you that you have a mother who has a PhD, who can read your essay and say, "Okay, let's change this around this, you know, I suggest this right?" That's so different than I grew up with an immigrant mom, who was a nurse's aide, she couldn't do that for me, you know what I mean? And so to bring that consciousness around, it's not just the test, or the grade or the getting into Harvard or whatever it is, because you come from an ecology, you come from a system that's either going to that you've beat the, you know, you've beat the odds, which is very few, or you've come with, again, generations of privilege and power and resource that's going to just keep...you know I think of the Kennedy family often because that's just like, that's like blue blood in America, you know?

Margaret Runyon :

Yeah, yeah.

Dr Mimi Niles :

We have to think about things that way and even teach our children that you know, like this isn't you're not it's not use your DNA but you're come people are coming with a lot of stuff that you don't have access to, you know?

Margaret Runyon :

Yeah, I think that constant just, you know, that weighing of our resources of our privilege, and being conscious of it, and then again, leveraging that is the, you know, the next step of it to realizing what you have that other people haven't had access to. And how do you move beyond that, then how do you how do you there's ways you can share that? Are there ways that you can, you know, redistribute it? And then all that...

Dr Mimi Niles :

Equity, right? Yes, but equity is right, that sort of I don't know either is like they just throw out the term equity. And equity means it's the distribution of resource is designed around who has historically not had that resource, you know?

Margaret Runyon :

Equity vs equality.

Dr Mimi Niles :

You don't give a community? Yeah, you don't give all community same thing and say, go all knock yourselves out. You know, you can't; like look at what happened in Katrina, look at what's happening in Flint, look at what's happening in Newark. I mean, you have to redistribute resources equitably with justice in your mind, in your heart and in your action. You know, same for nursing, same for midwifery, that's how I feel. We need to recruit more nurses of color, we need to recruit more midwives of color, and physicians of color to make the pipeline stronger. So that when you walk into a classroom, you have a professor like me, or you have a professor like Dr. Monica McLemore. You know, like, those are the kind of professors that we need to be; that's what students need to see, I think...so powerful.

Margaret Runyon :

and we can, you know, we need we do we need more voices to speak to the non-, what has been the dominant narrative. Because it's, that's not it's not serving all of us, but oh, my gosh, well, Mimi, I feel like we could probably talk, I could talk to you all afternoon, and like, you know, pick your brain about a million things.

Dr Mimi Niles :

Oh, I love talking to you.

Margaret Runyon :

Well, you thank you so much for taking the time to talk today and share your wisdom with us. I really, really appreciate it. I look forward to connecting more.Yeah,

Dr Mimi Niles :

Yeah, thanks, Maggie. I hope we stay in each other's orbit.

Margaret Runyon :

Absolutely.

Dr Mimi Niles :

Okay. Bye. Bye.

Margaret Runyon :

Thanks for tuning in to Your BIRTH Partners. We love to talk birth and we'd love to talk about it with you. Please join the conversation by finding us on social media, we're Your BIRTH Partners on all platforms, we would really love to hear from you; what inspired you about this episode? What really caught your attention? What are the topics you think we need to delve into more? And what are you doing in your community to change the state of perinatal health care to create a better future? Till next time! Transcribed by https://otter.ai