Supporting Healthy Families in the U.S.: Has Anything Changed?

Adriana Lozada: Welcome to Birthful. I’m Adriana Lozada.

Monica McLemore: We will figure this out. But today I’m mad, and I’m going to be mad, and everyone else should be mad because the childbearing families we serve deserve better and quite frankly, no one can push like the levers of the federal government.

Lozada: That’s Dr. Monica McLemore sharing her frustration on the day that the proposal for universal paid leave within the Build Back Better Plan got cut from 12 weeks to 4, and then was taken out all together. I was mad right there with her and apparently so were many of you, because what happened next was that, through the collective efforts of advocacy groups, private organizations, policy makers, and constituents who quickly mobilized to call their representatives, participated in marches around the country, and used the hashtag #SavePaidLeave to express their opinions on the matter, four weeks of paid leave were added back to the Build Back Better Plan that recently passed in the house of representatives. And in fact, one of my favorite moments of advocacy in that whole process was when over 24,000 people used the hashtag #SavePaidLeave to comment on one of Joe Manchin’s Instagram posts. Listen, I know four weeks aren’t nearly enough when the global average for paid leave is 29 weeks. And I know that there are no guarantees that these four weeks will remain in the plan as it still has to make it through the Senate. And I know that this is just the very tippy top of the iceberg in terms of all the things that need to change to get us out of the ongoing perinatal crisis we’re in, where according to the CDC, about 700 women die from pregnancy related complications every year, and we know that 60% of those deaths are preventable. Where we have one in six people report being mistreated during birth, where Black and Indigenous people are disproportionately harmed.

Lozada: But all of this is exactly why I wanted to talk with Dr. McLemore. Let me give you a little bit of context. Since 2017, when the World Health Organization first reported that the maternal mortality rate in the US had been rising for years, and it was finally acknowledged that we were and still are in a perinatal health crisis, there has been tons of research trying to shed light on why we have these dismal outcomes, and what we can do about it. Dr. McLemore has been deep in the conversations and research to find those answers for years. She breathes the stuff. So right now we are at a potentially really exciting time for policy change. The Black Maternal Health Momnibus is gaining momentum, paid leave is closer than ever to being passed since it was first talked about over 100 years ago. Postpartum Medicaid coverage is being extended from 60 days to one year in many states, and this extension may become permanent. And affordable high quality childcare is also on the table so, a lot of potentially exciting things happening. At the same time, it’s a really messy and often frustrating process. So I wanted to have a candid conversation with Dr. McLemore about where we are and what the road to good supportive and equitable perinatal care looks like. Spoiler alert, it’s a bumpy, nuanced, and complex road, but I hope you enjoy the conversation as much as I did. And you definitely want to listen through to the end for some amazing words of gratitude and encouragement from Dr. McLemore to help keep us all going. You are listening to Birthful here to inform your intuition.

Lozada: Welcome Dr. Monica McLemore to the show. It is really an honor to have you here, and I do appreciate you taking the time because you do so, so much to champion change in perinatal care for people. Why don’t you tell us a little bit about who you are, what you do, and how you identify?

McLemore: Well, thank you so much for making the time and for having me here and to your listeners, thank you for listening, I really appreciate you bringing bold attention to these issues. I am an associate professor with tenure at the University of California, San Francisco. I am a clinician scientist at Advancing New Standards in Reproductive Health, which is a program of the Bixby Center for Global Reproductive Health. And Thelma Shobe Endowed Chair in Ethics and Social Justice, which is a new title that I have. I’m a nurse by training and for me, one of the things that frames how I think about my work and my life is I am informed by reproductive justice. Which is a theory, a practice and a strategy that was developed by Black women in 1994 in response to the limited frame when we think about, birth and reproductive life course and when we think about the ways in which pregnant capable people are treated in our country. I use she and her pronouns and I think it’s really important that we point that out as well because, you asked me how I identified?

McLemore: I identify as somebody who cares deeply about humanity, I care deeply about work, I care deeply about fun. I am someone who has never birthed, never been pregnant, never wanted to be a parent, but has spent my entire career, as a researcher and a clinician. And I’ve been a licensed nurse since 1993, caring for childbearing families and pregnant capable people. And that’s because number one, I feel like the propagation of our species is really important. Number two, I believe in the future, and number three I’m a Black person. And so for me, it’s really important that we think about the ways in which we treat pregnant capable people and childbearing families because for me, it’s a barometer for our morality and our courage, and how we are willing to care for, or not care for members in our society. I have tried to tell people for the last 30 years that, because we can’t get prevention funded, that people always think intervention is the only way that we have to respond to public health and health services provision crisis, but that’s not true. So I would like to have a very serious conversation about what it means to be able to prevent maternal death, and my work spends a lot of time looking at those factors. This idea that maternal deaths come out of the thin air is actually not true. We know that people are mistreated during their pregnancy seeking care, I have data, I’ve published three different papers about that. And we also know that our perinatal workforce is broken, burnt out, inappropriately distributed, and undereducated. Then we have the whole situation of the medicalization of birth, when I always like to remind people that birth is a normal physiological process that most species on the planet experience, or at least mammals. So it is complicated. And at the same time, I think we’re smart enough. I think we’re creative enough. And I think we’re bold enough to be able to partner with the people we serve, to be able to make and build a better system.

Lozada: And so that’s a little bit of what the conversation that I want to have today because we know that we are in a perinatal crisis and a health crisis, the system is broken as you mentioned, I think you really hit it on the head with the whole, we focus on intervention versus prevention and being a birth doula and really focusing on physiology and how you can support your own physiology to help your body and birth flow, and knowing that interventions can make things worse, right? Like even getting an IV or being asked, what’s your due date? Your due date is an intervention. It’s going to create fear and create anxiety and all kinds of things.

McLemore: Or it will frame your experience because you’re beholding to something that is inaccurate and imaginary. That’s the other thing about obstetrics or perinatal care or whatever, I think see, in the medicalization of it, we’ve lost the sacredness, we’ve lost the magic, we’ve lost the uncertainty. And we’ve also lost this idea that when we use language like due date or when we use language like maternal crisis, we’re focusing people’s attention, without providing the context of the broader conversation. So for me, part of my work is to bring some nuance back into that.

Lozada: Yeah. Same thing that you were saying I mean, just by focusing on the due date, then I am creating a set of conditions that will make it so that if you go past that, so quote unquote due date whatever, then something’s wrong with you. I’m reframing the conversation that you are the one that something’s wrong with you. And I think that really, that’s a micro example but we do it at all levels through the healthcare.

McLemore: Yes we do. And here’s another example, right? The range of fertile women, at least for pregnant capable people is between 15 and 44, that’s like 30 years. And you will spend more time avoiding pregnancy than being pregnant, if you are one of the people who on average have between two and three children in the United States. So this whole conversation, about birth, about perinatal crisis, about all of it, it’s not grounded in a broader discussion about what is it that people need in order to be as healthful and dignified across their reproductive life course. Because people forget that birth is a episode, there’s a whole nine months that happens before said episode and postpartum is forever. So for me, I think we cause a lot of harm, in the language that we use and in the meaning that underpins that language.

McLemore: So I’m coming to you on this podcast today, very disappointed, frustrated, angry, and upset. On Monday, before I presided over the American Public Health Association’s session, I had a conversation with the health policy intern with Nancy Pelosi’s office. And he was telling me about how excited he was that we might get a vote on the Momnibus. And for your listeners, if y’all don’t know what the Momnibus is, the Momnibus is a set of bills that representative Lauren Underwood from Chicago and representative Alma Adams from North Carolina, introduced in the 116th Congress in 2020, which was nine bills at that time.

McLemore: And unfortunately, the first version of the Momnibus was introduced the Tuesday before we went on national lockdown. So it went nowhere. So after the 117th Congress was sworn in, on January 3rd of this calendar year, Lauren Underwood and rep Adams on February 2nd, introduced the second version of the Momnibus, which was nine bills, but they added three more. It was the original nine, and then they added three, one about vaccines, one about COVID 19 screening and testing, and one was specific to climate change, so that it could be part of the Build Back Better.

McLemore: And parts of it were also included in the American Rescue Plan, particularly the piece around the option to extend postpartum coverage to a year. This is a comprehensive package for us to join the rest of high income countries, and put some seriousness behind the financial and social and healthcare and public health supports that pregnant people need in order to be able to transition into that role with dignity and with skills and with power. 

McLemore: So I was very grumpy this morning to find out that in the negotiations around the Build Back Better, that we actually have the nerve to think that we could remove something as simple and low hanging fruit as paid family leave, from a bill, when we actually had a natural experiment last year during national shelter in place where we saw actually improvements in pre-term birth and birth outcomes, because people were sheltering at home and basically we had sort of a de facto experiment around paid family leave. So to hear that’s been removed from the negotiations and from us thinking about how to rebuild our social safety net, as well as our health services safety net, after a global pandemic makes me angry, and it reminds me that sometimes we have people in elected office who are cowards, and we have people who represent us who don’t represent our interests. And that perhaps maybe as citizens and healthcare providers maybe they need to be replaced.

Lozada: And, I think it also goes a little bit deeper into what you were talking about when you introduced yourself about how we care for families being a barometer for our morality. That, it’s not just the fact that it’s not being prioritized by the people who sit in these committees and in Congress and the Senate, but also we don’t really do good service and value for our families in general as a culture, unfortunately.

McLemore: So we expect one of the hardest and most significant jobs that people can do, which is to parent, right? To bring another human into the world and to try and shepherd them safely to adulthood, right? Because that’s what it is, I’m tired of people talking about this in ways that it’s like not, right? If people have the courage to want to do that in their lives, and I’m the aunt of the year to, I don’t know, 20 kids around the world, because I take that job very seriously. I am worried that we are in a position where it’s every person for themselves kind of situation. We have no clue or conversation. Nobody is having a discussion about what a public good even means, that there are significant investments that we want to make in our young people for readiness, for school, for being set up to be the next generation of people who lead our nation and our world.

McLemore: We’re not serious about that, if we can’t have a discussion about how to support pregnant capable people in the postpartum period. I’ll give you an example from my own research, I had a patient who was part of the Lyft economy. She had a C-section, right? Her mother had cancer. She was driving for a Lyft and a Uber 10 days after her C-section because she had no health insurance and no paid family leave. The last thing you should be doing is sitting in a car for eight hours postpartum as a Black person. Outside of the fact that you’re not able to be lactating and bonding with your baby, you increase your deep vein thrombosis or your risk of blood clots in your lower leg if that’s all you’re doing all day, right?

McLemore: We have a mismatch between what we say is really important and valuable, and what we want to financially support.

Lozada: It is deeply wrong.

McLemore: Yeah. When I think about, and this is another place where I don’t think your listeners and a lot of our citizens understand when we use the word infrastructure, we don’t just mean roads and bridges, we are talking about humans, money, time and space. And if you don’t think about that for childbearing families, then we are going to continue to do them a ethical disservice, in terms of saying they’re doing an important job in society but we refuse to recognize it.

Lozada: And we do that to our teachers, we do that to anybody in care culture, we let them know how little they’re valued by how little we support them on an emotional, physical, monetary and all of those, right?

McLemore: Exactly. Which reduces it all to one really big problem. Poverty is a policy decision, it doesn’t come out of thin air. These are choices, right? Because until we have a reckoning around those pieces, we will continue to see harm to Black, Indigenous, people of color, and queer folk, because that’s who’s being harmed right now.

Lozada: One of the things that really frustrates me also is how out of reach to that person giving birth, that person trying to care for their kids, that person driving the Lyft 10 days after having a cesarean. How out of reach the change feels. Where do we go from here? How can we imagine really good perinatal care? How we can we provide something for our communities right now while the bigger systematic changes happen?

McLemore: First of all, birthing people are sacred and the most tired people in the planet who are making the largest role transition that they probably will have in their lives, except for deaths of a parent or their own death. Unfortunately they shouldn’t have to be the people leading this charge. So if we talking retrofit, because I’m talking about retrofit, reform, and reimagine right now. If we’re talking about retrofitting our current systems, there are bigger levers that need to be pressed than postpartum families, right? This is why I like that employers are getting involved and trying to understand what are the supports and the needs that their employees need in order to be able to optimize their reproductive life course. We need the federal government levers to be able to do, we need the levers of business, we need the levers of philanthropy, right?

McLemore: It can’t just be the child bearing families trying to deal with this. That’s if we going to retrofit stuff. If we’re going to reform stuff, I think we need to make sure that when we are citizens we vote, and we vote for people who will understand our interests, and what we want to be able to see in terms of reforming our current environment. I mean they call the Department of Health and Human Services that for a reason, because one is about health services provision and human services is a social safety net that needs to go along with the health provision. Because you’re either going to pay for it on the front end or you’re going to pay for it on the back end. And we as a society need to really wrestle with that, and I think the almost 700,000 deaths from COVID 19 have taught us clearly, we want to be on the health side and not the human services side, right?

McLemore: So if we’re going to reform, we need a whole lot of other people dealing with this than childbearing families. And if we’re going to reimagine then, the only way to do that is with authentic and continual community engagement. The people who are closest to the problem, as Rep. Ayanna Pressley has said, are the people who are uniquely situated to know the solutions. And so therefore they need to have the resources to fix the problem. At some point I would like to see civil disobedience from healthcare workers because the places that we work are inhumane. It doesn’t work for us, it doesn’t work for the people we serve. That’s where mistreatment comes from, right? It’s not clinician burnout, clinician burnout is a whole component of that.

Lozada: And we see recommendations going into, oh, we know, what are some solutions that will make a change and then, midwifery care comes up as a really good alternative and having more doulas.

McLemore: When people say, “Oh, we need more doulas, we need more midwives.” To me that’s a heuristic, that is a shortcut. Because I always then say, okay, so how you going to fund the midwifery model in your current, if you’re going to retrofit some midwives and doulas into your, I said, first of all, they shouldn’t have to fix the problem that they didn’t create. So that’s a whole other conversation, right?

McLemore: So you’re either trying to retrofit them onto your model, in which case the secret sauce of what they do is going to get lost, or you’re going to reform your model of care such that the unique contribution that they bring in might be there, but it might be diluted. Or we’re going to reimagine this whole thing. And nobody ever wants to get to the third discussion, they always want to stay in one and two. But we got to do all three, right? Because here’s the other thing that your listeners need to understand, we can sit and talk utopias all day. Or when you think about Build Back Better or Momnibus, I think Momnibus was the floor and not the ceiling, just to be clear. But apparently that makes me really radical. But we have to remember that the utopia, right? That we all dream of doesn’t help the people in the now. So we need a “both, and.” We need people working on the utopia but everybody can’t be on team utopia because it’s aspirational and a lot of times you’re not accountable for making that happen. We still need people in the now. I say this all the time at workforce development, right? We want a ton of Black and Indigenous and people of color, queer birth workers. We want to diversify the healthcare workforce, we really want to diversify perinatal health workforce. Okay but what about those of us who are “onlies” right now, right?

McLemore: Those of us who are trying to do the work, it shouldn’t be our work to also figure out how to diversify the healthcare workforce. So when we think about diversification of healthcare workforce, that all sounds good, that’s always an aspirational future thing. But we’re never doing nothing for the people in the now, right? That are being harmed by our current system.

Lozada: Right. That’s the daily question. What do we do? And what we have right now is, for much as we think that it should the floor and our utopia is really big, the Momnibus is what we have that, the only thing that’s been able to gain some traction. What do you see is the future of the Momnibus? Where do you see us going from here?

McLemore: I’m not by nature an incrementalist. But when you’re talking about pulling the levers of philanthropy, the federal government, private equity and investment and business, it’s incremental. So on the one hand, I think that there are pieces of the Momnibus we’ve already seen this, right? The lactation piece got out of the House and was voted on already. The VA piece was in the mock up for Energy, Ways and Means. So, we can hold our frustration and disappointment with paid family leave this morning, right? We can hold that. That’s not a no, that’s a not now, right? If we were going to be emancipatory as human beings, our world would look very different right now. We by nature are incrementalists and a lot of people are uncomfortable with that, and I need people to deal with it. And if you’re not and you’re going to be, more courageous or you’re going to be more bold or you’re going to be what I aspire to, which is just badass than do it, stop talking about it, do it.

Lozada: Well, I think the incrementalists also, because I know my listeners are new and expectant parents. So they’re in that, as you say, very transitional space in their lives when they’re tired. And, what I want them to hear about this conversation is that it does take baby steps, but it also takes community. When you can’t show up today, your friend shows up, and then when they can’t show up, you show up.

McLemore: Or your sister, or your family member, or your auntie, or whoever, right? Again, going back to this whole idea that we don’t have a shared appreciation for what a collective good is. And I would love for us to have, I want that discussion. What is collective good in our current environment? And what are we all prepared to work towards? Not fight over or fight for. That’s the other thing, we got to stop with this, war language, fighting, metaphors, all of that, right? What are we all prepared to work for or work toward? For me, I’m trying to build, I’m trying to engage, I’m trying to endorse, I’m trying to align. And that opens up a possibility for the different kinds of work that we could be doing. So for me, it’s this bigger discussion of, in every single decision that we make every day in our work, how are we integrating birthing people? How are we making it easy for them to participate? Is it asynchronous? Are we paying them for their time and their expertise? Are we passing the mic? I can’t tell you how many press interviews this week I’ve connected moms with lived experience to a range of media outlets so that their voice, I don’t need to speak for them, they can speak for themselves. 

McLemore: So what are we doing to curate a space where people can bring the power that inherently exists in them? What are we doing to help them bring that forward? So for our new parents and the folks who listen to your podcast, like thank you. That is a courageous act. We see you, and we are grateful for this incredible gift that you’ve done to think that you could continue to propagate our species and bring new humans into the world. That is a big deal and it’s deeply appreciated. Because I can tell you as a childless by choice person, it will be your children who will design the tech I’ll use as an old girl. It will be your children who will take care of me as an old person. And as a professor, I’m grateful that I get to teach your children. I am grateful that I get to see them with the ideas that all of this could be different. I am grateful that I get to let clinicians and learners appreciate the fact that it’s a gift to serve you, right? That’s a really different narrative, than the stigma and shame and judgment and blame and fighting and all the other stuff that I hear, right? How are we going to build the partnerships that we need with birthing people to change our future. Those are the kinds of questions I’m interested in.

Lozada: And I definitely am hearing, and I want to amplify to the listeners the fact that they matter, to take to heart, you matter.

McLemore: They matter.

Lozada: Your experiences, your feelings, your struggles, matter. And find people who will understand that they matter.

McLemore: Yeah. Because we have the capacity to change this, we will figure this out. But today I’m mad and I’m going to be mad, and everyone else should be mad because the childbearing families we serve deserve better. And quite frankly, no one can push like the levers of the federal government when we are thinking about institutional change towards improving health services provision, and health services more broadly for child bearing families. They disappointed us today, but that’s all right because we’re going to keep pushing them.

Lozada: We’re still here. Absolutely. Thank you so much Dr. McLemore for your time, for all the work you do and for speaking to us today.

McLemore: I appreciate you having me and I’m happy to come back in a couple years hopefully when we’re celebrating, the next better version of Momnibus.

Lozada: That was professor Monica Rose McLemore, you can find Dr. McLemore on Twitter @mclemoremr. I hope your main takeaway from our conversation is that even though incrementalism is not very exciting, we have to keep the momentum going because you deserve better perinatal care, and so do your children and their children. This is work that we do together as a community by showing up as we can, when we can, by celebrating the victories along the way, and making sure our voices are heard even when we’re frustrated.

Lozada: So one thing you can do for you is to learn about the most common ways that people are mistreated during childbirth, and match that with the care that you are receiving. Go to birthplacelab.org/mistreatment for detailed information from the Giving Voice to Mothers Study article on Inequity and Mistreatment During Pregnancy and Childbirth in the US, which was coauthored by an impressive group of researchers that include Dr. McLemore.

Lozada: If you believe you are being mistreated, I encourage you to do something about it. With one in six people experiencing mistreatment during childbirth, this behavior is awfully too common, but that does not mean that it is okay nor that it should be tolerated. 

Lozada: Now, the one thing you can do for the rest of us is to continue emailing and calling your members of Congress to let them know that you support the Momnibus and paid family and medical leave. Specifically for paid leave, the Paid Leave for the US national campaign makes it really easy for you to send your email by finding the contact information for your members of Congress for you, and then providing a pre-written message that you can customize. To do all this, go to paidleave.us and click on the campaigns tab. It only takes a couple of minutes, but it truly does make a difference. 

Lozada: You can connect with Birthful full on Instagram at Birthful podcast, and to learn more about Birthful and my birth and postpartum preparation classes, go to birthful.com. 

Lozada: Birthful was created by me, Adriana Lozada and is a production of LWC Studios. The show’s senior producer is Paulina Velasco, Jen Chien is executive editor, Cedric Wilson is our lead producer, Kojin Tashiro is our associate sound designer and mixed this episode.

Lozada: Thank you so much for listening and sharing Birthful. Be sure to follow us on Apple Podcast, Goodpods, Amazon Music, Spotify, and everywhere you listen. And come back for more ways to inform your intuition.

CITATION: 

Lozada, Adriana, host. “Supporting Healthy Families in the U.S.: Has Anything Changed?” Birthful, LWC Studios, December 8, 2021. Birthful.com.