Can Doulas Help Fix A Broken Maternity Care System? A Conversation with Jessica from The Pacific Birth Institute
Have you ever wondered if you, as a doula, can actually help impact the declining state of maternity care in your community?
In Episode 43 of the Birthworker Podcast, I'm joined by Jessica Johnston from Pacific Birth Institute who is sharing her insight and experience from working as a midwife in Alaska and training birth assistants from around the world through the Pacific Birth Institute.
In this interview with Jessica, we chat about:
Why the mainstream midwifery training process is failing to facilitate relationship-based care…
How the data used in “evidence-based care” doesn’t apply to 70% of the population…
The ONE THING that would immediately correlate to increased health outcomes for marginalized communities…
… and a whole lot more!
Jessica Johnston: So now we have students who can register. They can take their time. This is really great for some of our stay-at-home moms that really love birth, but they're just at that sweet time in their life where they have babies, and we want them to be with their babies.
One of the big things we created this program for was to help people who wanted to enter the birth world, but who couldn't commit to the full-time schedule of doulas and midwives. But we need them. Just like OBs need nurses, midwives need birth assistants. So how do we create the infrastructure, the training, and the access points so that we can start growing community birth support in the form of birth assistants? Doulas, student midwives, midwives. Because right now, we know that home birth is returning so heavily. Home and community birth and birth center birth are becoming big topics.
It's not just because people are scared of hospitals. It's not just because of horror stories. It's a lot about infrastructure. We are losing 100 hospitals per year right now in the United States of America and it's creating in the United States, we have what we call a “maternity care desert” situation happening, where 50% of people who are pregnant have to drive over 3 hours at least to find primary care services for their pregnancy. And we know from all the data from forever, not just this year, not just last decade, but from forever, that a healthy pregnancy, a low-cost healthy pregnancy without a lot of excessive emergency room trips is directly correlated to access to preventative care, access to prenatal care, and access to education.
As midwives, we're like, "Oh my God, we need birth assistants. We need skilled people next to us." That's a big push for Jen and I as founders because we're midwives, and we know we need it, but it's not just us. We know that there are people across the United States struggling not only to afford maternity care services but actually to access them. When you see that and you also see a huge increase of people and clients wanting to deliver in community, it is our responsibility as stewards of birth to figure out the infrastructure that's going to support that. So Pacific Birth Institute focuses on education, entrepreneurship, innovation, and infrastructure. Those are our goals, to keep all of our centering, our students, everything centered around that.
When we talk about grassroots and we talk about community activism, it's really about how do we bring skills back into the community in a way that is sacred and sovereign, so matches the culture of the community, and is evidence-informed, so it keeps up to date. So we have the sacred and the science. How do we keep the sacred and the science on pace with each other? And how do we keep fresh financing, and just like a human eats food in the community itself, how do we keep freshness moving and how do we deal with any waste?
There's a lot of ecology in the infrastructure and community birth resurgence that has to be identified so that we do not make the mistakes of the indoctrination pathway that has led to 4x as many Black women dying. We cannot perpetuate a 1 in 3 C-section rate continuously and not preserve vaginal birth by over-medicalizing community birth practice instead of highly focusing on the cultural aspect of it, on the person-to-person peer support with some really great unkept, good evidence-informed information for saving lives.
I'm the Director of Development, and always with student development, program development, it is about centering those needs of the students in relationship to the ecology of the community mission that Pacific Birth Institute has, which is really to safely help restore community birth activism in the form of sacred skills that can no longer be gate kept, that are constantly being taught, apprenticed and moved through the community by the community according to the community's knowledge, appropriate data and cultural match.
Instead of allowing professions to be indoctrinated out, to remove doctors from community, to remove nurse midwives from community, to educate them in this power over structure and then return them to the community and hope that power with community led care, relationship-based care just somehow comes up. We have to shift everything, and centering student needs and the ecology of community birth are big aspects for anyone who wants to work on this side of the activism.
Kyleigh Banks: Yeah. I just love how grassroots it is. It’s on the ground, where we are in our communities, changing it from the community out. I love how you said we don't change the maternity crisis by sending people out to get trained and bringing them back. That's not community-based.
Jessica Johnston: So we focus heavily on our systems, knowing how to communicate with the systems in place because it is the responsibility of the systems in place to integrate community care. For too long, midwives have been told if we tried harder they'd listen to us more. For too long, we've been told "Oh, we'll just make one more committee, one more transfer committee, one more standard of care, one more scope, one more regulation." And then all of a sudden, the doors to OB will open and they'll be like, "Oh my God, we forgot. We love you. You're so helpful. Come on in. Let's integrate completely."
I try to be really clear about this. It is for us to know the language of the system, of which the "majority", I'm using big air quotes here, is involved. It's the responsibility of midwives and birth providers. When we do transport, it is our responsibility to know how to communicate as effectively as we can for the best care and the most seamless transport possible for the best outcomes for all clients and babies.
But that's where it ends, so we help our students right there. You're going to know how to soap, how to SBAR, you're going to know all the ins and outs, all the vocabulary, all the ADA that you need because we're going to hook it up. Then it's about strengthening the community where it's at. Actually all of those concepts of home birth transfer committees, I sit on some. All of these concepts of committees, integrating and networking who is already doing the work. The next big step for community birth experiences, for things like that to come alive is, who is really doing the work and how can we network them to stand firm in understanding that community birth itself is no less than hospital birth? Indeed, they are differently resourced situations, attending childbirth. They have different standards of care, they have different protocols in dealing with things because of the amount of people.
So when we talk about this, how can we get more health in the maternity care system? How can we save more lives? Integration is a big part of it, but I caution all women specifically and all midwives and doulas from overcommitting to the idea that if you just do one more committee, all of this shifts. It's bad rhetoric of the patriarchy. “The master's tools won't take down the master's house.” So when we watch destructive and sustainable paradigms, like, “Oh, if we just work hard enough, I'll just fix it.” This energy is just as destructive in the community to community members, especially those in marginalized situations, also known as sustainability, can be called white woman tears.
Unfortunately, it's where we end up getting no social movement forward, and yet a lot of people saying, I'm not sure if I feel safe with this. Midwives consistently, even against themselves, nurse midwives against professional midwives say, "I would want to trust you to do VBACs. I just don't know if you're trained." We're sitting here in the community saying, well, 1 in 3 of my consult calls is for VBAC. So if the doctors aren't trained in how to do it, and if 1% of nurse midwives are going to choose to serve the community and the other 99% are not, who's going to do it? You can't say it's an option if we don't make sure it's an option. Do you know what I mean? You can't say, oh yeah, breach delivery is an option in three places in the United States. You have rights.
We run into this barrier all of a sudden, and then it's the onus of, okay, so preserving vaginal birth is actually very correlated to good health data. We cannot have continuous, repetitive C-sections. It becomes very, very scary and very dangerous for singular people to have multiple C-sections, but then over generations, for us to start experiencing more surgical birth. We don't know where that's going to go. We probably don't want to push it too much.
I digress, but I like to bring up that when you're in community birth, it is good to be seated in knowing that who you serve is your community and centering your community. Because what happens in the politics of the community, the hospital, and the different access points of care, community care, and hospital care, is they get striated in continuously patriarchal systems. In a patriarchal system, it is based on putting one thing above another. It's a constant climb on a pyramid in nowhere, but it creates infighting.
We have nothing to fight about, we have people who need care, and we have doctors who are being trained in some of it and who are not being trained in some of it. We have a rise of unassisted childbirth happening across the United States for a plethora of reasons while anthropologically to be unattended in childbirth is slightly unheard of for the human species. So how are we at a place where they feel so in a position that they don't even seek support besides one or two people who maybe study a little bit? Nothing wrong with them, but my heart's like, shit, okay, great. I believe in birth too, I just sit in this space of community will be restored when all community members show up and demand that it be restored. Consumer and client-driven motives, products, community-centered anything is going to be really big this century going forward.
For me, it's ungatekeeping as much as we possibly can, basic education that never should have been lost by any community ever because of a power over system that told literally a midwife of four generations that you're dirty. You don't do it the way we did it in Europe, so now you can't. It's this concept of “the dirty midwife” that centers on patriarchy. It centers, “It's this way or no way.” What I love about being alive in this time and working in birth is now we get to ask the question when somebody says it has to be this way, we say, according to who? Because I have to sit in the space in Alaska, I serve a clientele that is half not white and half white, which is really different than a lot of white midwives across the nation. They serve a predominantly 70% plus white clientele.
But I work in urban Anchorage. I work in a city, and so half my clientele is not white, and I have to say this to them. I have to look at them and say, "So I'm going to talk to you about the evidence. I'm going to talk to you about the evidence of anything. I'm going to talk to you about your informed consent for the concept of induction, going to 40 weeks, going post dates." And as I'm talking to them about whatever evidence we're consenting on at this point in care, I also have to, because I'm informed, say to them, "I'm going to be honest. The data for this evidence probably doesn't apply to you. It is probably actually based on white women predominantly in a completely different economic strata, different part of the world, different religion, different entire upbringing. So I've got to be honest. When we go forward in your care, this is all I know to look at. I'm only informed so much by it."
So we can use this evidence? Really it's what we have, but does it apply to you or 70% of the rest of the population that's giving birth? No. And so this evidence-based to evidence informed movement that's happening in the community is also decentralizing the patriarchy. It's saying we're going “unaccording to you” when we talk to our clients, because what is midwifery? What is community birth? Do you think I go in and pull babies out with handles? Are there any handles? There are no handles. Do I get on their belly and push, make it go faster? No.
In the end, power with care and community care is really based on the edict that we're going to take care of each other, and that actually nobody knows better than your community members, you, and the relationships you've developed and the work you've done, and how the community has been able to uphold the sanctity and sovereignty of its birth practices and evolve and continually learn and bring more students in and fuel its own apprenticeship processes.
That's my goal. That's where I want to go. Because sovereignty is not just about an online curriculum that people can take. It's not just about, oh, I took it. No, I'm going to go work with one midwife. It's about the social consciousness of moving away from power over to power, with which means however it's done, if the person feels aligned with it, and they feel most supported, and it actually is backed by evidence, that's their culture, their community.
For me, it's about bringing the evidence way more central, studying as much as you can in your local community, not using these overarching, well, if you're not white, induce at 39 weeks. When you dig deeper into some of this research, and it's because they were studying impoverished areas and they're worried that these women can't catch buses on time for their appointments. It's easier to induce than to let a woman go to a natural due date because she doesn't have the resource access to match the OB getting to the OBs office on time.
What do midwives do? Where do you think I see most of my clients? I see them at their home. I don't centralize my resource needs. I centralize together mine and theirs. I meet them where they're at. And that bigger development is not, “I guess we need to induce more because we're underfunding community development,” because we're closing hospitals at a rate of 100 per year and then wondering why people can't get there. And then we're just saying, we'll just cut the babies out, or we'll just induce. It's like, this is power over versus power with. Power over is just like, well, fuck it. We're going to cause nature to bend to our will. No, no, no.
In fact, when you double down on destructive paradigms, they implode exceptionally, which is what we're seeing with birth data in this generation right now. They're doubling down, things are not going well, and what's happening? We're having a huge jump ship. People are coming to the community, people are going unassisted, but they are saying, I think I need to look at something different because this data is horrible. So yeah, we talk about programs and I'm like, it's a social issue.
Kyleigh Banks: Seriously is. Yeah.
Jessica Johnston: It's a political issue.
Kyleigh Banks: Yeah. I loved every single word about this entire thing. I'm just mind-blown. You tackled so many things that now I hope people are going to like re-watch this and be like, okay, I need to write down all of these and go explore them. Because there are so many golden nuggets. Everything from the maternity care desert to people driving 3 hours, 50% of people driving 3 hours. That's insane. And I don't see it every day in my life because I don't live there. And so I'm in this little bubble, like, “Oh, the hospital's 30 minutes away.” But it's like, no, wake up. Hello. There's something much bigger going wrong here.
Jessica Johnston: We still maintain our scholarship commitment that we scholarship one student for every five that enroll. And we preferentially scholarship to rural maternity care desert areas, serving underserved populations, which is kind of redundant because if you're in a maternity care desert, everybody's underserved. Yes, but we try to scholarship students of the global majority specifically in these instances. If we were to look at this from a really data-driven perspective, in my little humble midwife opinion here, if we are really honest about the evidence that we have right now, we would be as a nation, highly scholarshipping and highly accelerating and hyper bringing in non-white providers as fast as we possibly could into every level. We're talking OBs, every level of service, I'm sure. ButI'll focus on maternity. Every level of maternity care provider position across the nation.
If we were focused on data and we really wanted to reduce unnecessary maternal death in this nation, we would be committed to actually specifically hyper-accelerating the education of non-white providers everywhere right now, because that would correlate immediately into reduced C-sections, and so much reduced loss. We see loss, especially based on lack of cultural match in the OB setting, where we see it most is in pediatrics. A baby under the age of one year old that is a Black baby and is seen by a white pediatrician, has a huge increased risk of death in that first year, but if they are seen by a black pediatrician, that risk is gone. I'm not making it up. Look it up. The internet has it.
So we need to start paying attention to what diversity really means when we look at healthcare administration. It doesn't mean filling these quotas. It means sourcing as continuously from community for community as possible so that all demographics are consistently represented in the community in this constant flowing fashion. So that you're apprenticing so that you can match all needs from sourcing your actual community members. I mean, makes more sense than hiring out. I feel like the outsourcing game has kind of shot America in the foot at this point. So we definitely want to start reinvesting in the people around us if we want to see birth providers over this next generation.
Kyleigh Banks: The scary thing is that your thought right there is the minority. Other people have the blinders on, the ear muffs on. They're like, well, let's double down on outsourcing, authority, and let's double down on researching rich white people in the suburbs. And it's scary, the direction is scary.
Jessica Johnston: Yeah. It's one of those, “Well, what is centered?” In a power over paradigm, what is centered is profit. So when you have profit as the underwriter that actually has more sway on the bureaucracy or the legality of a hospital, which means they have more sway on even a midwife's ability to practice autonomously in the hospital, that's what happens. And when you center profit over people, when you center a paradigm of destruction for profit over a paradigm of power with and for people and actually say, how can we restitute forever the sovereignty of this skill into every community so that we actually take low-risk birth completely back off the docket of the hospital purview completely?
We start developing them independently and allow integration to happen as it's going to, and actually enforce legally with emergency orders, the legalization of midwives in every state now, and encourage and fund the integration between hospitals and community birth now. This is how I would be spending money.
But it's different. It's a different perspective because we come from working in communities. I did not leave my community to become a midwife to my community. And there's so much to be said about that. I served a 50-mile radius under 5 different midwives, serving all different Hindu communities, Muslim, we have a ton of old believers and Russian Orthodox, all sorts of community members. Because Alaska is the most diverse state. So Alaska is an exceptionally diverse state because we're kind of this port city up here, so we have a lot of people with the military.
I learned in my community, as all community members should, for 3 straight years while doing my education, while studying on call 24/7 for 3 years, I had 2 weeks off for my wedding. Yay. But this is where the pandemic made it so hilarious for me right here. What more could I learn from being on campus specifically underneath specific people? Not near my community members, not actually practicing shoulder dystocia moves in the field, not actually landing IVs on slippery bleeding mothers, not just on mannequin dolls in labs. The pandemic made it great because it's like the entire college system's going to totally shift because now.
It's like you guys made a lot of money on specifically the housing, the orientation, this administrative level to make sure these kids could access this education. Well, yeah, now we have online. Education is being ungatekept exponentially and being shared everywhere at community levels. So I think there's a lot to be said for what's happening. I think it's hilarious. And I think it's also really lucky that online education is going to get such a big boost after such a sad pandemic reason. But that online education is going to make education more accessible and kind of bust down some of the doors of college gatekeeping, because I couldn't even believe this when I realized it.
Did you know that in the 80s and 90s, so again, my lifetime, all of our most current medical research, the money, our tax dollars paid for, remember that, tax dollars go towards this, you couldn't access it unless you were enrolled in medical schools, unless you were enrolled in these higher collegiate? And I'm looking at everyone, but your tax dollars, plumber man, paid for that. Your tax dollars, window guy, paid for that. What do you mean you can't access the actual results of what our tax dollars have paid for the growth of humankind? I think that is what you're going to start seeing a lot more of in this generation is that we're going to get ours either way. All humans are going to get theirs either way. And all of these towers, all these power over. Once you're good enough, you can join us. Man, we don't even want to be at your table. Actually don't, we're doing our own thing. You do you.
With midwifery specifically, this big push towards licensure, a lot of states now are like, is licensure helpful? I mean, licensure is actually starting to get questioned. Is licensure helpful? And I'm a midwife who's licensed, and I have watched our board and I have watched all these things just get delayed, delayed, delayed. "Oh, we'll table it. We'll table it." And we're talking about people getting VBAC coverage. We're talking about insurance stuff. We're talking about things that if we had it written into our statute and law, we'd save real people real money, but they're not sure if we're safe enough because we're not doctors.
So they want to talk to doctors about midwifery practice. Do you think doctors know anything about what we do? Not at all. No. It's a different lane. I don't need them to know what we do. It'd be cool if they wanted to, but I don't need to know everything they do. I respect them. We just want to be respected. We want to be like, instead of, these dirty midwives, I'm not sure if they can help, be like, well, nobody else is, and you guys are dying on the vine. More doctors are retiring than coming in. More people are returning to the community and you want to just double down, but my way's the only way. Well then we're not going to keep playing with you.
I know for myself, I get snippy about the efforts of licensure and how I think it may be, we might be noosing ourselves in certain instances, as much as I really stand for the expansion and the payment of midwives. Licensure in this country can be heavily tied to that. It's a double-edged sword. So when we talk about centering, we talk about students.
Kyleigh Banks: I love it. I love how you just make it so clear that it's not just about the skills, it's not just about the knowledge and the knowing. It's just so much deeper than that. And that's why people probably choose you to work with and choose Pacific Birth Institute to work with, because it's not just go watch this video and learn this skill. It's like, yeah, how do we dismantle all this shit that's going on? And how do we take responsibility and stop asking people to tell us we're good enough and to just go be good enough?
Jessica Johnston: Exactly. Exactly. Why are we centering the opinions of OBs? Why are we centering the opinions of boards of people who don't even know what we do? Why are we not centering our clients, centering our students, centering the generational longevity and legacy of birth per community? This is what I want to center. It's funny though, because every time I work with a marketing person, when we're trying to do anything for the business side of PBI, they're like, "How's the person going to feel taking it?" I was like, "Socially on fire." And they're like, "Are they wanting to feel socially on fire?"
Kyleigh Banks: I think they are.
Jessica Johnston: I don't know how to answer that. I mean, if you are in community birth, welcome to the revolution. Welcome to it. Now be aware of what parts you play, because you will, you are playing a part in it. So this is that time where we're like, whoa, what parts are we playing? But yeah, if I was to try to dress this up all pretty, I'd be like, imagine feeling so confident, listening to fetal heart sounds, listening to a baby take its first breath, and hearing both lungs inflate and being able to say to the midwife, “bilateral auscultation of lungs.” Does that feel good? You want to know how to do that too? I could sell it that way. I'm a social justice fanatic. So I try to remember, how does the student feel learning the material? Oh, hella informed.
Kyleigh Banks: And also close your eyes and envision the patriarchy burning. And every woman has access to a community midwife within 30 minutes of her home.
Jessica Johnston: Yeah. Well, I mean, we're so on the social justice side of it, our program is completely... We did a lot of degendered language. We founded this in 2019 and then the pandemic hit. But even when we founded it, the number one thing we said was, we're going to make it accessible for all clients. And that really is the inherent difference with power with versus power over. I'm not going to tell you not to do it and then do it. I'm going to be with you and I'm going to show you, I'm going to apprentice with you what it looks like to be a steward of community birth, who is learning from those of the community that I'm centering. Something big was going on at that time, and Jen and I were like, it is not hard. It is not hard. Watch. I'll write 60 hours, thousands of pages of curricula and it will not be an issue.
So yeah, believe me, the social justice goes deep, but I will say this, there's no right or left. There's no red or blue involved in the curriculum because we're midwives, we're professionals. This is all about getting people trained in the routine and complication care management in home and birth center settings. So at our skills weekend, we were doing lots of cool stuff with teaching the students how to release shoulder dystocia, how to give bimanual compression, we teach IVs, we teach administration of meds, what meds we use in the community birth setting. We teach how to identify fetal position, listening for fetal heart tones. This is really good first year for pep midwife students to student midwives who really need distinct skills training. We've created it for them too.
This is about taking somebody who wants to work with midwives and getting them like a year into an apprenticeship, an everyday apprenticeship, getting them into it in as fast as they want to go through a curriculum. The foundational anatomy and physiology all the way through prenatal care, all stages of labor, newborn, complications of newborn, all of it, and postpartum. We go through it all. And it's really just the skills.
And then the community extrapolation is really up to the community. We talk about the most evidence informed skills that we're using. We talk about community meds knowing that not a lot of people can have them, which is ridiculous because it's ridiculous to be able to even say to a provider on a legal standpoint that they cannot carry Pitocin and be considered a safe community provider. That there are certain states that this still happens. I could be arrested for what I do in certain states.
We are teaching as much education as possible for anyone, no matter where they're at, if they can get all the meds, we're teaching all the meds. If they can't get the meds, we're teaching bimanual compression, we're teaching shock treatment. We're teaching all of the things. Because in Alaska, you go outside Anchorage or Wasilla about 30 minutes, and you are in the middle of nowhere, and EMS response time is 30 minutes plus. You have a hemorrhage, you have a baby not breathing, you need to know what to do to keep them alive and stable for transport. We focus heavily on that because why? Because it's a maternity care desert out there. And so we're not trying to hide the real skills of childbirth. I need everyone to know the real skills of childbirth. And it is not rocket science, but it is a skill. There's education involved with identification of what's going on in labor. There's so much. And this is not a midwifery institute. This is a birth institute.
This is our flagship program. We have other stuff available, but this program is specifically for anyone who wants to work in birth, no matter who. We've had OB med students, doulas, all sorts of people take the program. This last skills weekend was great. We had two EMTs, we had one nurse moving to Australia to join the Australian Midwifery Program, which was awesome, we had a stay-at-home mom and we had a doula. So I mean, we get some fun walks of life all joining to know more about community birth. Yeah. Okay. I'm rambling about community birth.
Kyleigh Banks: I love it. Wrap it up one more time. I know everyone knows who you are, but who are you? Where can we find you? Where can we sign up for the program? All that good stuff.
Jessica Johnston: Yeah, totally. So my name is Jessica Johnston. I am the Director of Development for the Pacific Birth Institute. Jen and I are kind of taking it easy on social this summer, but we're on Instagram, we're on Facebook. One day, we'll do TikTok, I'm sure. You can email us, you can find us on our website, pacificbirthinstitute.com. One big thing I want your listeners to know before they go, is on our website, there is an interest form that is open to everyone to complete. We run skills weekends here in Alaska, followed by rotations with nine different midwives across Anchorage and Mat-Su area. We are considering opening our 2023 residency and hosting with lodging and transportation students up to eight weeks to get birth experience with eight or nine midwives here in the state if they are having a hard time getting birth experience outside.
And so there's an interest form for people. We're going to open it up because we don't want to saturate our own market. This last five we put through, this'll be our last five probably for another year and a half in the Anchorage area. Next year's training is going to be open to people from across the lower 48 in the world. So eight weeks of on-call, you'll have a place to stay with other students. You guys will all bunk up together. You'll have a little car there to use to get to births. And then we're going to have a cool wellness thing at the end with other providers. We would have the ability after that, I'd hook up with a lot of our friends that do fishing trips here in Alaska, just being in Alaskan. So if we would have options for packages at the end for fishing, backpacking, all sorts of cool Alaskan stuff. So you guys can have an Alaskan week vacay after.
So if anyone's interested and wants birth, what does that look like? You get to come up, you do a big skills weekend with Jen and I and the midwives for four days. We certify you in neonatal resuscitation, BLS, CPR, you get IV training, you get all the training, and then we turn you loose with nine different participating midwifery practices in Alaska on a schedule. So you guys all schedule yourself. You get about 30 days on call a piece on this rotation, and you're going to be doing 24 to 48 hour on-call shifts, backing up midwives. So you get lots of different birth experience in different settings, home and birth center with different practicing midwives, which is great. Because if you're a pro-BA student, a professional birth assistant in our program, you need five laborers to certify as a certified professional birth assistant. You have to go put your skills at the test.
So our students just finished their skill weekend. So they're running with our midwives right now on call. And then next year we'll do another one in the summer, but that one's going to be open to everyone else. So if you're interested, just fill out the form. There's no commitment. If people are interested, we need to know because we're not going to go to the length of putting it together if we don't have people who want to do it. So yeah, let us know.
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