Know What You’re Up Against When Giving Birth At A Hospital

Mimi Niles, a full-scope midwife and midwifery care researcher, talks to Adriana Lozada about the U.S. hospital system, how your goals as a birthing person are at odds with the system’s goals, and how to tap into your power as a consumer within the system.

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Know What You’re Up Against When Giving Birth At A Hospital

Adriana Lozada:

Welcome to Birthful. I’m Adriana Lozada. 

Dr. Paulomi “Mimi” Niles: Anytime you engage with a system, can you look and analyze that system and demand that system to treat you like a whole, full human being? 

Lozada: That’s midwife and researcher, Dr. Mimi Niles. Her work seeks to improve the perinatal experience for all people and focuses on addressing the complex systemic issues in perinatal care.

Now, given that this episode is part of our series on Models and Places of Birth, and that  most births in the US happen in a hospital, Mimi is the perfect person to talk about what it means to give birth within that system. She and I will also be talking about how your goals as a birthing person might be at odds with the goals of the hospital, and what you could do about it.   

And to be honest, at points, this is not an easy-breezy conversation because the system is filled with what can seem like insurmountable complexities. At the same time, if you’re birthing in a hospital, it is really important for you to know what you are up against ahead of time so that you can prepare and set things up to have a better birth experience. 

Now, this isn’t to say that you can’t have a dream birth at a hospital –in fact, in our next episode with Jenny Murphy she shares how she did just that, and I also have a condensed episode for you titled “How to Have a Great Hospital Birth,” to further help with your preparation. 

You’re listening to Birthful. Here you inform your intuition. 

Why don’t you start out by telling us a little bit about yourself and also how you identify? 

Niles: Sure, so I’m Mimi Niles. My pronouns are she and her and I identify as a midwife. I identify as a mother, doing mothering and parenting work. As an immigrant Brown woman, that’s the body that I live in. And as an engaged Buddhist, which is trying to bring my spiritual practice and my social justice practice in conversation with each other. 

Lozada: I’m fascinated by that, because— especially how it ties to our conversation— but first, say I am a pregnant person giving birth at a hospital. What do I need to understand about how that system works and how I fit into that system? 

Niles: I’m a researcher as well, which is sort of a new identity, and that’s one of my, I feel, guiding research questions, is trying to understand this system, right? Although I will say, it’s not a monolithic system, so it really is dependent on your location, and your geography, and your state, down to the very granular of your town, or village, or city, and then even within that city, I happen to be in New York City, which has the largest public healthcare network in the country, so it really depends on what system you’re seeking out your care in. But in the U.S., that’s actually one of the problems and challenges of the U.S., is that you cannot speak about a system, because there’s multiple systems happening at the same time and they’re functioning in either for-profit models, or public models, or hybrid models, so I don’t have an easy answer for that, but I think it is worth people or users investigating what systems they have access to and what services are offered in those systems, and how their insurance impacts very clearly what choices they have and what they have access to, particularly in perinatal care or maternity care. 

Lozada: So, you brought up a great point about insurance companies, and the insurance system, which, when you’re thinking, “I’m gonna go give birth in a hospital,” you’re probably not thinking about how the way insurance works with the hospital specifically or with the care provider specifically, how that ties into the care you will receive. 

Niles: Yeah. I mean, it’s— unfortunately, it’s a fee-for-service model. It’s an incentivized system. It incentivizes volume over quality. And that is sort of the basic tension of maternity care in the U.S., particularly around midwifery here, because the midwifery model of care is about intervening less. It’s about supporting a physiologic process. It’s about supporting the whole change over time, right? Which is what, to me, pregnancy is, and labor is, and birth is, and parenting is. It’s really change over time. And so, models of payment are not structured for, sort of, the long-term gains of a particular care model. They’re really structured around you do a service, you get a fee. And that incentivizes intervention. It incentivizes a more sort of what we call a technocratic model of care, where the technology is what’s driving the care. The intervention is what’s driving the care. And that, as we’re seeing, does not work in maternity care, because in essence it’s a physiologic process that really needs protection, guidance, a safe space. 

It doesn’t mean that complications cannot arise. They do, either in the prenatal period, or in labor, or postpartum, and that’s when you do need a specialist, or you need intervention, or you need somebody with a skillset, right? Sort of a technician who can help you address that. But that is not the case for most people. 

Lozada: So, what would be a model of payment that is more structured around supporting the long-term change over time process that you mentioned? 

Niles: I work in a system where the midwives in the practice, we’re a public practice. We’re not privately paid. We don’t get paid per birth. I get a salary, so some people call that the laborist model. So, basically you go in, you do your hours, you get paid for the work you do. And there are some studies to show that actually the quality improves in that type of model, because the provider is not engaging directly with trying to build their bottom line. Basically, they’re coming in and doing good work for 12 hours or 18 hours, and then they go home, and they get their paycheck. 

So, in my practice for example, all the… 90% of the vaginal births are with midwives. So, the risk condition doesn’t matter. You could have preeclampsia. You could have gestational diabetes. You could have both. You could have three things, four things. You’re still, if it’s a vaginal birth, it’s gonna be at the hands of a midwife. So, I really am trying to also get the midwifery world, and the clinical world, and the health services world to think about midwifery care as more expansive, because we’ve always been sort of pigeoned into this low risk, low risk model. And I think that has a lot to do with sort of the hierarchies of care and how care is structured, but midwives can actually do good birth no matter what the circumstance is, because birth is a process for anyone. 

And so, it’s really about who’s there to contain and support and to guide that process, and can insurers and hospital systems realize that this is what the client values? Versus what the system values, which is something very, very different, right? The system values efficiency, and the system values bottom lines, and you know, not being in the red and all those kinds of things. When a person— a human pregnant person— goes into the hospital, I don’t think they’re thinking about all of those things. You know, like, “What’s gonna make my hospital more money?” or “What’s gonna make my provider more money?”

They’re not thinking about those things. They’re thinking, “Who’s going to make me feel seen and where am I going to feel cared for? And who’s going to give me and show me respect and my partner and my family and my other children? And who’s going to respect that I work 9-to-5 and I can’t take a day off every time I have to go for a clinic visit?”

Lozada: Well, and I think that’s a great point in that there are two different focuses, right? Like as a person giving birth, you are focused on the compassionate, equitable, dignified care that you mentioned, and also person centered, and I would think when I envision my utopia of care, it would even be person-led care, but how that is so at odds with what the hospital system that you are stepping into to give birth has as their priorities, and we have lots of ways to measure whether an intervention is “needed,” or was done well, or did its purpose. But we don’t have things embedded into the system that measure whether the person is feeling seen, whether they’re feeling heard, whether there’s trust. 

So, I want to jump ahead and say how do we change that? Because we know that’s something that a person is gonna experience when they go in. 

Niles: Yeah. I mean, that is also the million dollar question, because I think it goes way, way back, and it goes into how these institutions were designed and erected and what the purpose of those institutions was. And I think we’re in a moment of deep, deep rupture and reckoning in the U.S., and you cannot and should not be literally given a microphone about maternity care in the U.S. and not talk about the absolute disrespect that has been laid to bear on Black women, Indigenous women, women of color, immigrant women, refugee women. What we’re seeing right now, the news reports of forced sterilization. This is not new for those of us who have been in the work. This has been happening since the birth of this country, since the colonization of this country. A woman’s womb has been a commodity. It’s a place to make money. It’s a place to produce workers. It’s a place to increase your investment, grow your wealth. 

Or it’s been a place of control, right? It’s a place for people to say, “You’re having too many babies. We’re gonna tie your tubes and we’re not gonna tell you about it, because you’re burdening our system.” Right? A system that really was never created to take care of poor people, to take care of people of color, to take care of immigrant people, to take care of people who built this country. The more I learn, the more I think these systems were actually built to keep people out, to keep people shut out of places of power, places of control. For example, in midwifery, only 2% of midwives identify as midwives of color. That is not reflective of who we are as a country. Of OBs, I think it’s something like 8% of OBs identify as Black. 

So, I think it’s more than just the episode of care. It’s all the pipelines that come into care. Insurance, public health infrastructure, the workforce pipeline, the nursing education, medical education. It is just an absolute maze of what has been created to exclude people, and now we’re at a point where particularly public health systems, because that’s my interest, where the predominant people who are going into that care are marginalized and minoritized people, and we’re trying to use the same systems that were used to exclude them, and so what ends up happening is people come out of that system broken, and hurt, and harmed, and then we scratch our heads and we wonder why, you know? 

So, I’m particularly interested, and this is like I’m just being unapologetic here, but the full on integration of midwifery care into maternity care systems, because they’re not accessible in the U.S. We represent about 10-12% of all births in the United States. If you want to talk about community birth— and I’m talking about home birth or birth center birth— that’s even less: it’s hovering around, I think, 1.5-1.8%. Is Medicaid paying for it? Are insurers paying for it? For the most part, back to that insurance question, no. They’re not gonna. They’re not paying for home birth at the same rate, so the home birth midwives are fighting to get… They do a birth and they have to fight to get paid for that birth, you know? Or they have inequitable Medicaid reimbursement, so they’re disincentivized from taking on clients who have Medicaid, because Medicaid pays so little that there’s no way to run a business and take Medicaid-only clients. 

Lozada: At every point of the discussion that we’re having, at every point we find barriers of access. Barriers of access determined by the systems, determined by the power plays, determined by the hierarchy within the system, and I also want to talk about that, because I know… I know. I definitely know the power of midwives and how the midwifery model of care compared to a technocratic model of care makes a huge difference in these outcomes of feeling you have a better experience. Not just that at the moment that you left the hospital, you and your baby were healthy, but longer term. But what I think doesn’t get talked about as much is also all the other players and how they structure, and how that hierarchy, that power system that you talked about gets perpetuated for the people— and violently so— for the people that are in the system trying to provide care 

And so, we have OBs, and midwives, and nurses, and then the nurse manager, and the administration, and then in terms of the doctors themselves, you have residents, and whether they’re first year, or second year, or third year, or they’re a fellow of their students. That’s a lot of… Can you untangle that web a little bit for us? 

Niles: Oh. I can try. I’ve been in clinical practice for going on 16 years and I’m still trying to figure it out. And I would say I work in a system that— and my research too, and I did my initial research on midwifery care in the public setting— I specifically chose midwifery practices that didn’t have residents, because I felt like that was a variable that I couldn’t control at all. And I really wanted to see what care looked like with that trifecta of physician-midwife-nurse, right? So I can speak a little bit about residents, but in my own clinical practice, I have not worked with the residents very often. But residents are basically physicians in training, right? They’ve finished medical school. They’re going for their… I would call it almost an apprenticeship. That’s how midwives are also trained. We’re trained in a very apprentice model. We sort of shadow a midwife and we do everything that they do, and that’s… You learn by doing.

I think the way that power is organized in healthcare is pretty clear. I’m just gonna say it, but it’s the physician is on top, and everybody else is on the bottom, so I wouldn’t even call it a pyramid. It’s sort of like… Maybe it’s a pyramid, but on the top are the MDs. They make the decisions. They’re also on the top of they’re the insurance company CEOs, and they’re the managed care plan CEOs, and they’re the… So, it’s not just hospitals. It’s not some person sitting in the corner office. It’s every decision that’s made, the who gets licensed in the system, and who works in the system, and who gets credentialed, and who gets hired as the administrators in the system…  It’s very, very physician-heavy and physician-centric, really. So when people say “person-centered,” the opposite of person-centered is— I’d say— the opposite is physician-centered, you know? And that really is how the model runs, is consolidated power by the physician. And in some ways the justification is, “Well, we have the training and we have the knowledge, and this is our space where we do the work.” 

But it’s not, because like for example when I think of obstetrics, and I really, when people say, “I work in obstetrics,” I say, “I don’t work in obstetrics.” I work in midwifery. Or I work in maternity, right? Obstetrics is designed to, as it should be, is a surgical technocratic specialty. They are surgeons. That’s what they are, right? 

Lozada: And that’s the knowledge they have. They have a knowledge of surgery, which is-

Niles: Yes. We want it. We need it. You know. 

Lozada: Yeah. When we need it, right? When we need it, we are so happy that they’re there to provide that when things get pathologized, or pathology shows up, then you need them. But we know that in birth, that’s not usually the norm. Birth is not pathologized, and so when you say about them holding the knowledge, and so they’re… It’s clinician-centered because they hold the knowledge. Well, they hold the knowledge to a very specific thing that we are prioritizing but is in fact in dire opposition of what birth needs. Which is bringing it back to that mindfulness that you so center, because it’s… You need oxytocin to flow. And for oxytocin to flow, you need to not feel fear. You need to be safe, protected, loved, treated with respect, seen, treated with dignity, all of these things. 

Niles: Yeah. Yeah. I mean, I have physician collaborators, and that’s how it should be, and I want to go back to that idea of can other forms of knowledge be honored and respected in this space? Right now, I feel like it’s very hard for the medical model to consider and regard and welcome, because that would be the ultimate, to welcome in other forms of knowledge, right? Because midwifery is an ancient, ancient, ancient tradition and practice that has been central to every community since we were human communities. It has lost its way because of power, and because of politics, and because of capitalism it has so lost its way in the United States, and we are driven… Capitalism is what drives this country. 

You know, if you cannot see that now, then I don’t know when you’re  gonna see that. You can pay for the best kind of care that you want to have. But what about the people who have public insurance, or regular insurance, who are working people like me, who I can’t afford an $8,000 out of pocket cost right now. And so, I think again, so many systems were designed to consolidate power, and if knowledge is power, then you also try to consolidate what knowledge means. Right? And so those are randomized controlled trials and “evidence-based medicine,” and all that kind of lingo and jargon that you hear, to me, is all a power play as well. The person I’m taking care of has their own body and their own family system and their own culture and their community as their resource— that is valuable knowledge. And the knowledge I bring as a practicing midwife who’s done hundreds and hundreds of births, when I just know that everything’s okay, even though the tracing might be off, or the contractions aren’t strong enough, but I know, because there’s so many changes, micro changes I’m watching and observing in this person I’m taking care of that I know that their body is transitioning. 

You know, I can’t prove it to you on the monitor, but I know, because I’ve had so much lived, embodied experience. But it doesn’t count for anything, because where do I put that in the chart? Where do I put that in the medical record? 

Lozada: The mortality rate is horrible all across the board. I think the U.S. right now ranks as 54 for high-resource countries. And then if you are a Black person, then you have higher risk of dying from giving labor, so we are spending almost as much, twice as much money as anybody else in our healthcare system, and our perinatal systems, and we’re having some of the worst outcomes. So, just unpacking like what does that really mean? 

Niles: And it’s not even just maternal mortality. It’s what’s even worse or the underbelly of it is maternal morbidity, which means severe illness in pregnancy, in the labor process, in the birth process, in the postpartum process. Something sometimes people call near-misses or near-deaths, which is just like a chilling term that people who are sort of at the brink of dying and then brought back, so those numbers are even worse, and I’m hoping that those of us who are in the work in a different way, maybe in a more academic or clinical way, we’re really also starting to think about morbidity, the severe morbidity crisis, as that means like severe hemorrhage, or eclampsia, or things that we have the tools, and the resources, and the technology to avert those things, and we’re still doing worse than other countries in terms of those markers. 

And to me, it’s also the deeper spiritual root of that is what is the collective consciousness and commitment of this country to families? To parents? To mothers? To women? I don’t see that there is a deep collective commitment to that, even though that is the building block of any community. That is the building block of family, is to me square one, piece one of a building block of how do you create, and grow, and sustain healthy communities? 

Communities make up towns, communities make up cities. They make up states. They make up our country. And we’re failing. We’re failing families and parents and mothers and fathers and grandparents and— 

Lozada: Well, and we know that however a person is born into parenthood, that that dictates, sets the tone of how they will parent. What happens during the birth sets the tone of how you will parent, and it sets the tone of how that little person, that baby will grow up. Your postpartum experience is going to be very, very impacted by how you birth, and how you birth is gonna be impacted of how you’re taken care of during pregnancy, and so forth, and we can go all the way back. But back to the system— 

Niles: Sorry. I totally went off on a tangent there. 

Lozada: Me too. Back to the system. 

Niles: And power. I want to talk about power. I challenge my students to and the collaborators to view all of these issues, and challenges, and tensions through a power lens that was shaped for me by Black feminist thinkers, Chicana thinkers, Indian feminist thinkers that their lives were dictated so much more clearly by power structures and power systems, because they were so excluded from them that they could see them more clearly. When you’re in it, you can’t really see it. And I don’t believe institutions have souls, so let’s make that really clear: institutions are soulless. They are not— we should really refrain from humanizing them because they are not human. So they’re not really gonna care for you. They’re not gonna love you. They’re not gonna protect you. They’re not gonna… I mean, they have mandates to do no harm, but to me that’s like the bare minimum of what somebody can do, is not harm you. And I think the healthcare experience has to be way beyond not harm you. To me, it has to be we will enhance you, we will make you more whole, we will try, we will not break you more, you know? 

Lozada: We’re all, I think we’re waking up, we’re naming the thing, and we’re trying to figure out how to reinvent the system, but while we wait for that to happen, for that pregnant person that I mentioned at the beginning that is walking into a hospital to give birth, what are some things they can do to balance out the power towards themselves a little bit? Like how do they do that work? 

Niles: Yeah. I struggle with this question a lot, because I feel like we have to demand more of the system, like that’s number one, right? And in some ways, I feel like it’s unfair to ask a solitary person to be their only advocate, or a person and their doula, or a person and their partner, or a person and their grandma, whoever that might be, to take on this sort of massive system and say, “You figure it out and you advocate for yourself.” But I do think that there… If the system’s gonna treat us like a customer, then we should act like a consumer, right? And so, that means doing the research, finding out what’s available in your community. Know that if you choose care and you have an option to choose midwifery care and it’s supported by your insurer, and if it’s not, that again is a whole other sort of conversation that you could have with your insurance. Say, “I want this, and I demand this of my care, and I know that this is cost savings, and here’s the research on how much midwifery care is gonna save your company in costs.” 

Because we know that the midwifery care is relationally-based, so it’s a relationship-centered model of care, so the care itself is rooted on building the trust between you and the midwife or the midwives, depending on what that practice looks like, and that’s something we call “continuity of care” in the jargon. It’s sort of you have this person that over time, because pregnancy is a process, you have this person that you’re building this relationship with over time, so that they get to learn not just what you tell them, but just what you bring to your care, because again, that’s gonna change on every visit. What you’re going through, who’s important to you, what values you realize about yourself. The trust builds. That’s really important. Your sense of autonomy will build, where you feel like because your provider trusts you, you’re gonna feel like, “Oh, I can tell them what it is that I really want for myself, or what I hope for myself in this experience.” 

Lozada: Well, and I think it’s really important for them to be clear, to take a step back and be clear on what it is they want for themselves, and what… Even more of what they want, what they need, and so for example, and this is something I work with my doula clients so much on, is do the work of examining where you’re at, because that’s what you’re bringing into your birth, and then what do you need to support and help you through that? So, for example, if you’ve experienced trauma in your life, you need a provider that’s trauma-informed. If you are a people pleaser, you need to figure out how to strengthen yourself to be able to speak up. And here we are. You, Mimi, and I, giving everybody who’s listening permission to say “No.” Permission to ask the doctor if they can call that doctor by their name instead of Dr. So-and-So, because back to the hierarchy, midwives are Mimi. You’re not Midwife Niles. You’re Mimi. And the nurses, they’re Karen. That shows you the structure of the power. 

Niles: Absolutely. Absolutely. And I mean, not to be super crass here, but this person’s gonna have their hand in your vagina. The most intimate thing is gonna happen in a way that demand… You get to make… You give consent. And I think that is a phrase that you need to wire into yourself: “You don’t have my consent.” Say that and learn that. Look in the mirror and practice. Whatever kind of technique. Write it down 25 times every day. “You have my consent.” “You don’t have my consent.” Because that’s the language of the hospital, is about consent, and we are seeing more and more experiences of people having non-consented care. What the hospital calls “refusal of care” is actually people telling you, “I don’t give you my consent.” This basically means, “You don’t have my permission to do this.” 

And you know, and it can be small. It can be like releasing the membranes, and you say, “You don’t have my consent,” unless you want to have a really good conversation with me about why this might be needed, or why this might be beneficial to the labor and birth of my child. You don’t just get to do it and pop. And, “Oh, I released your waters.” No. That’s not how this works. So, get that part of your vocabulary going. 

And again, absolutely Adriana, you have my permission, and you have my support, and you have my… All the generations of Indian women behind me telling you. You can do this, and it’s your body, and it’s your choice, and you have autonomy. Because there are people who don’t have that, right? I mean, that’s happening right now in this country, where people, their wombs were taken away from them without them knowing. That is the extreme of what can happen. 

Lozada: It is horrendous. Horrendous. 

Niles: But it happens on the micro level to us, the potential of it happens on a micro level of every care episode, of every care experience, because of the power dynamic. Exactly what Adriana’s saying. It’s the power dynamic that allows it to happen. And again, if they’re gonna treat you like a customer, if they’re gonna treat you like a bottom line, then you treat them like they’re giving you a service, you know? If that’s what it demands, even in the public system. 

And I guarantee you, I’m 45 years old and there’s things about myself I thought I knew that were solid, that are not so solid. You know, I don’t even know if it’s about knowing exactly who I am, but it’s knowing what my process is and knowing, you know, how I am in certain situations.

And what am I like when I feel intimidated? What am I like when I feel like someone’s more powerful than me? Or what am I like when I feel less than or invisible? Those are more important than “I’m going to take a stand,” because that’s not… I’m not wired that way, you know, I’ve never been that way as a person.

So that’s the deeper knowing of like, what is this going to look like? Because we know for a fact that certain things are going to be challenged. You’re going to be challenged in certain ways. 

Lozada: Yeah. And we also know that when you’re giving birth, you’re in a more vulnerable state, so unfortunately it’s when you’re walking into the hospital that it’s too late to do the work. Like we know, you and I know that the work needs to be done, like you were saying, even before you’re pregnant, but demanding— having this consumer approach to it from the first contact— and if something’s not working? Fire and rehire, right? Like, how hard… it’s super hard work. I get it. 

Niles: It’s hard. 

Lozada: But our… you need to have relationships you can trust. And if you’re not building those relationships, so if you feel less than when you’re in the presence of your provider. When it— I mean, the system, like you said, is already rigged to make you feel that way, because the power is given to not you.

So even… Make sure you bring in somebody. Bring in… As a doula, I have witnessed the room change and what is being said when I walk in. And that’s horrible to say, because it shouldn’t be, but it does. So, and it doesn’t have to be a doula. It can be your partner, your family member, a friend, but arm yourself with numbers, I guess. 

Niles: Yeah. Yeah. I also tell people to choose wisely who you bring: it’s not a show, it’s not a sporting event, you know, it is a super sacred time. and I want to say something too… You said it’s a very vulnerable time, but it’s a weird thing, because it’s very vulnerable, but probably some of the most power that you’ll ever experience in yourself, so it’s both these things, where you feel super raw because you almost have to to eject a human being from your body is super… You’re literally very vulnerable, but you’re also in one of the most physically powerful, I would say spiritually powerful places that you could be, so I think it’s a both and. It’s not an either or. 

Lozada: Agreed. 

Niles: I really see people struggle with both things. And I think a lot of times the media has done us dirty in terms of like, what people are like when they’re laboring and they become these like, raving lunatic people.

And yeah, if that’s what you are in real life, that’s what you’re going to be. You know, like that might be heightened, but I mean, I’m in the hundreds and hundred, 800s teetering up to a thousand births, and I have— I can count on one hand when I have seen someone just really just be so far off, like, off their baseline.

And usually it’s related to— like you said before— like some trauma is triggered or something like that happens. 

But you know, like that advice of… it’s not like falling in love, but I tell people it’s that feeling of falling in love. You know when you meet someone and you’re like, “They’re so cool. I really like them. I don’t know why, but you know, I just think I could vibe with them.” And that’s about intuition, too, I think, which is another part of our sacred selves that we’ve really kind of squashed, and numbed, and kind of distrusted. Especially I think people who identify as women have been told that’s not a legitimate form of knowledge, so don’t do that. I know I was told that. I have very strong intuition, but was told like, “Where’s the evidence for that?” I grew up with scientists in my home. Like, “What’s the evidence for that feeling that you have?” And the world will do that to you, and it’s really if you have a strong intuition, grow it. Build it. Because you’re gonna need it as a parent, too. 

Lozada: And your intuition is also heightened. 

Niles: Yeah. 

Lozada: During that pregnancy and birth state, because to me, so the tagline for the podcast is: “Inform your intuition.”

Niles: Ah. Perfect. 

Lozada: And so-

Niles: And you didn’t tell me to say that. 

Lozada: No, I did not. It’s “inform your intuition” because to me, intuition is other ways of knowing, is ways of knowing that aren’t centered around your thinking brain. But all of those other parts of you are as powerful as that thinking brain. We just don’t give it as much stage presence. 

Niles: Yeah. And I think that our culture is designed to really delegitimize it. 

Lozada: So, I always ask, if you had to pick one thing that people need to do for themselves, what would that be? 

Niles: I do think that it is our collective responsibility as childbearing people in the United States to learn the history of childbearing in the United States, and what the medical system, the experimentation and the violence that was done on enslaved women, and how that’s the roots, those are the roots of modern gynecology and obstetrics, and I couldn’t have said that two years ago without fear of offending physicians or the obstetricians that I love and adore and I work with and respect and admire, who themselves don’t know the history of their own profession. 


I mean, to me, those are, you know, you should like… you want to get pregnant and somebody should just hand you a pile of books or you do the Audible or whatever it is, not to scare you, because that information and knowledge and history should not be used for fear. It should be used to empower you to understand the roots of a system that does not protect your autonomy and does not treat you as a sovereign person, right? Who gets to make decisions about themselves.

And so, I would say reacclimate yourself of childbearing as actually being a site and a location for feminist principles, like how do you enact feminist principles in your healthcare? Because now I feel like it’s cool to be a feminist, but it’s so much more than a t-shirt. It’s about anytime you engage with a system, can you look and analyze that system and demand that system to treat you like a whole, full human being? So, that’s what I would want for people to do, is really learn about what the history is in this country because it is violent, and upsetting, and so deeply disturbing, it will also help you understand what the experiences for Black women, and Black femmes, and Black childbearing people in this country. It’s really something to understand and develop deep, sort of fierce compassion around that. 

Niles: And the other thing I would tell people, too, is stay curious in the work, because pregnancy is one thing, but so is parenting. And to me, this is all a continuum. I feel like some of the first decisions I had to make as a parent was who my provider was and how I was gonna labor and birth. Those are decisions that you make for your child, you know? So, start thinking of it that way. Decisions that you’re making for the health of your child. And not just your own, and that people should know that labor, and pregnancy, and birth, and parenting, it’s a dance. It’s a dyad. You’re in it with somebody else, right? Even if there’s nobody else in that labor room with you, there is another human being who’s waiting for your support and your guidance through the world. 

Lozada: Mimi, thank you so, so much for this fun, fabulous talk. 

Niles: Yeah. Thank you so much, Adriana, and I really appreciate being invited on. Power to the people. 

Lozada: That was Dr. Mimi Niles. She’s the only appointed midwife to sit on the New York City Maternal Mortality and Morbidity Review Committee and she also serves on the board of directors of the National Association of Certified Professional Midwives and the New York Birth Center Association. You can find her on Twitter @mi_niles. That’s M-I-underscore-N-I-L-E-S. If you want to learn more about the different birth models and how they affect your birth, I’ve linked in the show notes a previous Birthful episode with Robbie Davis-Floyd, as well as the All About Midwives episode with Missy Cheney. 

I hope your main takeaway for our conversation with Mimi Niles is that it is vital for you to understand the context and nuances of the system where you will give birth so you can use your consumer voice to speak up and demand that the system treat you as a full human being. One thing you can do for yourself is to learn the history of childbearing in the United States. To that end, Dr. Mimi suggested a few books. They are Medical Apartheid by Harriet Washington, Killing the Black Body by Dorothy Roberts, and Medical Bondage by Deirdre Cooper Owens. 

You can connect with us @birthfulpodcast on Instagram. In fact, if you are not driving, it would be lovely if you would take a screenshot of this episode right now and post it to Instagram sharing your biggest takeaway from the episode. Make sure to tag @BirthfulPodcast so we can see it and amplify it.

You can find the in-depth show notes and transcript of this episode at, where you can also learn more about my small birth preparation classes, and download your free postpartum preparation plan.

Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte. This episode was produced in part by LWC Studios: Paulina Velasco, Virginia Lora, and Cedric Wilson with contributions from Kat Hernandez and Ronald Young Jr.

Thank you for listening to and sharing Birthful. Be sure to follow us on Apple Podcasts Spotify, Amazon Music, and everywhere you listen.

Come back for more ways to inform your intuition.


Lozada, Adriana, host. “Know What You’re Up Against When Giving Birth At A Hospital.” Birthful, Birthful, April 20, 2022.



Mimi Niles, a brown-skinned person with short graying hair, is standing with arms crossed at the chest, and is wearing black rimmed glasses, a blue shirt, long necklaces, and bracelets, with delicate tattoos visible on her right forearm

Image description: Mimi Niles, a brown-skinned person with short graying hair, is standing with arms crossed at the chest, and is wearing black rimmed glasses, a blue shirt, long necklaces, and bracelets, with delicate tattoos visible on her right forearm

About Dr. Mimi Niles

Mimi Niles, PhD, MPH, LM (she/her) is a full-scope midwife and a midwifery care researcher based in New York City. Her work explores the potential of integrated models of midwifery care in creating health equity in historically disenfranchised communities with complex care needs. She is extensively trained in utilizing critical feminist theory, as theorized by Black and brown feminist scholars, and qualitative research methods to generate policy and programming rooted in intersectionality and anti-racist frameworks. As a researcher, she hopes to generate midwifery knowledge as a tool to build equity and liberation for marginalized and minoritized people.

Dr. Niles is an active member of the midwifery in her local and national communities and has received various awards including the Johnson & Johnson Minority Faculty Award and the Jonas Nurse Leaders Scholar Award. Dr. Niles now serves on the Board of Directors of the National Association of Certified Professional Midwives. Her most rewarding work to date is as the mother of her two glorious children, born at home with midwives.  She is currently an Assistant Professor at New York University and an active collaborator at The Birth Place Lab at the University of British Columbia She continues to practice midwifery at Woodhull Medical Center in Brooklyn, NY.

You can connect with her on Twitter, Instagram, or her website.

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