Is 'mom-centric' perinatal care even possible?
That’s a complicated question…
“These are invented problems. They can be solved. We just have to decide to solve them.” – Anu Sharma
My first thought when I walked into the Millie clinic in Berkeley, California last May: “Damn, I wish this existed when I was pregnant!”
I had popped in to visit the co-founder and CEO, Anu Sharma, to chat about all things maternal health and get a tour of the clinic that opened its doors in 2022. The whole clinic radiated the energy of a hug. I could feel my shoulders drop, my body reflexively take in a deep breath and a long exhale.
The attention to spatial details was always part of the plan. A clinic that doesn’t feel clinical. With cozy, washable gowns to change into. Soft lighting, soft scents, soft music. Spa vibes. An atmosphere that somehow manages to communicate “we got you.”
Millie is one of few startups rethinking (thoughtfully) about the way women’s healthcare is delivered. A “modern maternity clinic” housed in a building directly across the street from the hospital where I delivered both my babies over a decade ago.
Millie popped back into my head after seeing the response to the Ignored Health Risk of Motherhood post
and the way the interviews with Dr. Devika Bhushan and Dr. Rachel Somerstein resonated — how the process of birth centers the baby and fetal/infant risk and feeds off the self-sacrifice of the “good mother” narrative:
“If women are expected to deprioritize their own humanity from the very minute they begin carrying a bunch of cells (that may or may not turn into a baby), do they even have a chance of dislodging the maternal martyrdom framework for every other aspect of parenthood?”
So many elements in those discussions and considerations of how to reduce stress during this phase of life, came back to the question: “what would healthcare look like if we started from a mom-centric approach to pregnancy, birth, and postpartum?”
Millie seems like a pretty darn close example of what is possible1 Not only does the vibe of the clinic space demonstrate priorities around experience, the Millie model of care also centers the birthing person and their body, as emphasized in a stated core belief: “We trust you with your body. We put you at the center of your experience because we believe in both human intuition and clinical excellence.”
The model revolves around a hybrid care structure that brings together midwifery-led care with doulas and OB-GYN support (80% of pregnancies are considered “low risk” and will do just fine with Certified Nurse Midwives), using a culturally competent care model. If additional medical needs arise, the hospital-based OB/GYNs (remember, the hospital is directly across the street at their Berkeley location) and/or MFMs co-manage care. Babies are delivered at the hospital but the Millie care team is present to support the entire process, even for c-section. A trained doula, a Millie Guide, provides emotional and educational support throughout the pregnancy and postpartum and is available for questions at any time. Additional wrap around support services bring together access to education, lactation support, mental health support, and facilitated community support groups. All in one location. And once the baby is delivered, the first postpartum check-in occurs within the first week, in your own home, and includes discussion of infant feeding and care.
And this model works.
Early data show a decrease in NTSV C-section and a decrease in preterm birth with the biggest improvements (against national averages) for Black mothers. Over 65% of parents diagnosed with perinatal anxiety or depression were in remission by the end of Millie postpartum care. And this is just the start of the positive outcomes they are tracking.
But even if you are in the camp that doesn’t give a shit about maternal outcomes, Millie has continued to prove out that a midwifery-led model of care is financially viable AND cost-saving (in many places but not all… but more on that later…)
Fast-forward to a few weeks ago when I sent off an email to Anu: “I wrote something recently that seems to really have hit a nerve and I wanted to do a follow-up about the solutions that already exist and the (possible) future of maternal healthcare – specifically, a mom-centric approach to perinatal care – and that idea just screams ‘MILLIE!’ to me. Let’s chat!”
Anu responded immediately: “My overall take on the current state is that the desire for a baby boom is not compatible with the current maternal health care model or the already low reimbursement rates that are driving physician burnout & killing OB practices. We are not going to see much progress until we start valuing mothers and those who care for them. I know this isn’t particularly uplifting and am happy to speak to the more positive work we are doing, but am mindful that it can mask the realities of what innovation needs!”
Woof. I knew we were in for an interesting discussion
With an administration that wants a “baby boom” while planning drastic cuts to Medicaid, limited access to critical tools and medicine needed for OB’s to do their jobs, ignoring any need from the humans carrying, birthing, and caring for those booming baby, it’s more important than ever to target the most effective levers of change. It’s tempting to join the “blow up the model and build something better!” rally cry (yeah, it's me) but the conversation with Anu added a critical angle: how do we ground the rally cry within the constraints of the healthcare system, target the right levers of change, and continue to effectively move the needle forward.
[Spoiler: it mostly comes down to economics and public funding so this is also an urgent reminder to call your Senators because if the fucking “Big Beautiful Bill” passes (even writing that name out makes me want to vomit) in its current form, Medicaid will be chopped and the math that didn’t even work well before will become even more problematic.]
Maybe this won’t be the uplifting addition to Maternal Stress Project solutions as I had hoped? But working within the reality of current constraints is key to effective change so, here we go…
MOLLY:
We’re in a weird time to talk about the current and future state of maternal health. It feels like there has been a lot of progress but we’re also in this moment of set back?
ANU:
I’ve found, and I’m sure you’ve discovered this too, that everyone seems to have a lot of angst about the issue. It's like, a big shining problem that is just glaring. It's a moral issue. It's an economic issue.
“Even if we built something that was perfect — got the capital, jumped through all the hoops operationally to make this happen— it still can only reach that many places because of the constraints.” — Anu Sharma
We can shout from the rooftop that this is a broken thing and everyone should have [a much better version]. And I'm like, ‘well, [“better”] can only exist in that many places.’ Even if we built something that was perfect, got the capital, jumped through all the hoops operationally to make this happen, it still can only reach that many places because of the constraints.
Healthcare is not a national market. It is a series of regional, and sub-regional markets, each with their own peculiar payer-provider dynamics. Not all markets are going to be viable [for certain solutions/companies]. There are other conditions to consider: such as the size of the market or the availability of providers. [Companies trying to succeed in this space] need to thread a needle through six stage gates of what could actually work, financially.
What I have concluded from all of this is that 1) you have to have a public sector solution to be the safety net in parts of the country where private sector solutions simply are not going to reach. We need to accept that as truth. And 2) the reimbursement structures are a massive, massive issue in the maternity space.
MOLLY:
It's both frustrating and refreshing to hear you immediately bring up constraints.
Considering the consumer/patient side, women are definitely getting loud about what they expect out of healthcare, and that is a good thing, in many ways. I think we are starting to see this come up clearly with the perimenopause/menopause category, for example – this hunger for answers and the expectation that solutions exist and should exist for everyone everywhere. But we can’t ignore the reality that there are healthcare system constraints that the average person (well, a majority of people!) cannot see that will always continue to affect access, until those constraints are fixed or broken, right?
ANU:
In order to take hold and scale as a solution, you have to operate within the intricacies of our healthcare system. You have to work within the reimbursement structures, contract with payers, and not drown under provider shortages or broken operations.
Women's health has never been the place in the hospital where money is made. It's subsidized by other specialties.
“These OB deserts exist because the economics are just awful in many parts of the country.” — Anu Sharma
In the maternity space, when you have an OB practice which is not in a hospital, then you have this scenario where the global bundle reimbursement structure is completely insufficient. More specifically, unless there is a meaningful enough volume, [independent] practices cannot function because they don't have all these other subsidizing features to offset the costs of actually running a 24x7 practice. On top of that, not only is the reimbursement structure bad, but the fact that it's a “bundled” payment, which means it comes at the end of the care episode i.e. 6 weeks after the baby is delivered (actually even longer, factoring in when the claim is paid) so the financial float actually sits on the practice. It’s completely unacceptable.
That’s why there are OB deserts. These OB deserts exist because the economics are just awful in many parts of the country.
Without a public sector solution and some major fix to reimbursement to make practices viable (to the extent they exist and can exist in certain markets), we can't get there. It's not possible. And that's before we've even talked about the state of the state of the science!
MOLLY:
Wow, yeah! We haven’t even talked about the state of the science! Or patriarchal medicine. Or biased and skewed priorities. Any of it!
There are a couple questions I’ve been thinking about after talking with Devika Bhushan about postpartum sleep protection and Rachel Somerstein about c-section and pain dismissal and birth trauma:
What would it look like to prioritize mothers and have a more mom-centric approach to perinatal care? For example, in those earlier conversations, we discussed the importance of emotional support and psychological safety. Now I’m struggling to hold this question in this context of the reality for women's healthcare in America.
Is there a way to hold the question within the realities of the system? Or do we need to blow it all up? Or find a middle ground of starting with case studies while we try to create a culture that continues to beat the “there is a better way to do this” drum? Continue proving it out while we wait for a public sector to wake up to it?
What is the path in? Where do we start to even chip at this problem?
ANU:
In my view, this is a solvable problem. We [at Millie] are working on solving it.
We lead with midwifery care and partner with health systems to provide the full continuum of OB and MFM level care when needed. We make ourselves available as early as someone needs – they may be experiencing symptoms, it could be a miscarriage, it could be an ectopic pregnancy. We follow ACOG visit guidelines from there, but we also fill it in with other things. We have doulas who are available to answer questions at any time. That frees up clinical time and makes for a better patient experience. We have a lot of curated resources in the Millie app. We have continuous remote patient monitoring and devices, so you have a little bit more of a continuous stream of data. We leverage the patient’s own involvement in their care by educating them on common symptoms versus clinical signs so that they can proactively co-manage their pregnancy with us. We’re there for the delivery. We do a postpartum home visit within the first week with an optional virtual visit at the two–three week point and then the standard six week visit [in clinic]. We are available, continuously through all the different touch points.
“the prevailing maternity care model in the US falls short of what “care” people really need.” — Anu Sharma
Conclusively, we have demonstrated great outcomes. If you take a comparable population – a good fit for midwifery-led care, within our risk scope – and look at outcomes, our outcomes are better and we have positive actuarial ROI, which means, from a payer perspective, it makes sense to do this. We have very high patient engagement and feedback scores. We have some of the largest health systems in the country wanting to partner with us. So all-in-all, we have demonstrated a model of care that can be better with the ability to scale to more markets with more partners who want this model.
There was a recent paper published by JAMA on the state of maternal mental health having become much worse. At Millie, we see very similar rates of perinatal anxiety & depression at intake vs. national data, but we see very meaningful rates of remission by the time people end their care with us. We take a prevention-focused approach i.e. we believe that proactively giving patients the information & skills they need to navigate the pregnancy → parenthood journey creates peace of mind, confidence, and preparedness. This is another example of how the prevailing maternity care model in the US falls short of what “care” people really need.
[ You can read more about this HERE]
“We can solve this if we choose to.” — Anu Sharma
The question for us really is – how do you take the Millie model and put it in more places?
I think about that question in two parts: the first part of the question is: do we know what to build? And the answer is yes. The second part of the question is: can it stand on its own weight? Can it exist with viable economics, good outcomes, good patient engagement and experience, positive return for payers? The answer to all those things is, inclusively, yes, we've shown it.
This is a solved problem. But now it depends on, do we have the will to make it ubiquitously available? There are places [in this country] where this model is just not viable. So the bigger question is: do we have the will to scale it? and what is our solution for places where this cannot be scaled because the economics don't support it?
There are private funders who get behind companies like Millie, because they have a mission alignment, but they're not big enough to support the whole weight of the system building. They can help build access in some parts of the country where you could put a company like Millie [with only private investment]. You need the public sector to step in elsewhere.
“42% of births are paid for by Medicaid. But Medicaid reimbursements are absolutely ridiculous, to the point where providers don't want to care for Medicaid patients or provide care in predominantly Medicaid communities. The economics are so bad that providers simply cannot do it.” — Anu Sharma
But on the public support side, the way Medicaid is structured gets in the way; it becomes a state by state thing. 42% of births are paid for by Medicaid. But Medicaid reimbursements are absolutely ridiculous to the point where providers don't want to care for Medicaid patients or provide care in predominantly Medicaid communities. The economics are so bad that providers simply cannot do it. Are we, in the end, shooting ourselves in the foot by having such low reimbursements that we create bad outcomes? Maybe we should just raise those reimbursements so that we don't have to pay the high downstream costs that come along with bad outcomes and access issues.
We can solve this if we choose to.
MOLLY:
What does public sector support look like? Is that policy to change reimbursement structure? Is that public dollars invested in healthcare?
ANU:
It's reimbursement dollars, the absolute value of those reimbursement dollars AND the timing of when they are paid out.
From a [global obstetrical package] perspective, the reimbursement covers all of the visits after the first visit, excluding labs and ultrasounds. This would be about ten or so visits with labor and delivery, paying something like $2,300 on average. That's what a doctor would get paid for visits and all the labs and all the ultrasounds and delivering the baby. That's a mind blowingly low number given everything that is involved. Contrast that with an IUD insertion, which is about like $1,200 in reimbursement for a 20 minute appointment. That includes a device, but nevertheless, from a doctor's perspective, would you rather insert an IUD or take care of a maternity patient? That's the difference. And then you have malpractice insurance which can be as high as $100K per provider in some markets.
The math is just not possible. And Medicaid reimbursements are even worse, which is why OB deserts often overlap with Medicaid-heavy markets.
MOLLY:
Back to your statement that this is a solvable problem. How do we solve it within those constraints?
ANU:
You can solve this with midwifery-led care to a large extent. Not everyone needs an OB. Midwives are appropriate providers for most pregnancies. They're also less expensive than an OB. You can right size the care team. You can use technology to fill in care between visits. You can put a lot of things in the hands of patients so that they can participate alongside their care team.
The new ACOG prenatal care guidelines further goes on this right sizing point. They now say that not everybody needs the same schedule of visits and it depends on the nature of the risk of their pregnancy. [They acknowledge] that some people need more psychosocial support and less clinical care.
“I just think ACOG’s new guidelines are an aspirational goal for where we are now. For things like this, you could shout from the rooftops, but it makes little difference until grounded in the realities of how current reimbursement is structured.” — Anu Sharma
Now that's very theoretical. How do you model reimbursement against that? How do you go from a global OB payment model, which assumes a certain number of visits and some blended average looking at c-section rates, to this guideline which leaves it up to the provider to establish a “tailored visit schedule streamlined around needed education and services”?
MOLLY:
So what are the new ACOG guidelines based on?
ANU:
I imagine there was a lot of research that was done along the way but there was one seminal paper [orienting the new guidelines]. The paper does make a ton of sense and I have spent a fair amount of time with some of the researchers behind it.
But I do think [ACOG’s new guidelines are] a bit of an aspirational goal for where we are now. Even coming from ACOG, with all of us shouting from the rooftops, it is a massive leap from the realities of how current reimbursement is structured today and how insufficient it is.
Even if you are wringing the dollars out of the efficiencies, you cannot get to financial stability. Reimbursement is a hard constraint. Unless you solve that, you cannot solve the broader problems [for everyone].
MOLLY:
So, what is possible… in certain places?
ANU:
We are building an improvement over the current model, and we're becoming a replacement function in markets that are losing access because we have essentially reconstructed the economics of a practice to work within current reimbursement structures. Unlike other traditional OB practices where it's just not viable at their cost structures, we make it work with our hybrid model that blends in-person care, technology, and health system partnerships in a completely different way. (I don't believe in the virtual-only model – as much as they may say that you can bridge care with a virtual-only model, there is no care, you have to be the care! There are real limitations.)
“The biggest gaps in health outcomes are in locations [with significant constraints]. What happens in those places that really, really need a better model? The public sector will need to step in. Especially in the states that have suffered the most. Especially in the states with very severe provider shortages. ” — Anu Sharma
So… Do solutions exist? Yes. Do we have the ability to scale them? Up to a point.
We’ve proven that you can do this. But we also know this will not be a ubiquitous solution. You can put [a model like this] in a lot of places, but you cannot put it everywhere. You can only put this in sufficiently dense markets with the right health system partners.
The biggest gaps in health outcomes are in locations that do not have that patient volume and the density, and where the public safety net hospital is not sufficiently funded to keep its labor and delivery unit alive. What happens in those places that really, really need [a better model]? The public sector will need to step in. Especially in the states that have suffered the most. Especially in the states with very severe provider shortages. With rural populations, or not very dense populations, where the economics are really challenging for any private sector solutions to truly reach, the public sector has to step in.
MOLLY:
Something you mentioned in your email – the level of burnout in obstetrics that also affects accessibility of any degree of perinatal care across the country – do you feel like there is enough of a shift in the view towards midwifery care to see more widespread adoption of it? Where are we now in the state of how obstetrics views midwives in a way that would allow the field to say “hey, we're drowning here. You're a trained professional who is specifically trained in the female body and birth, come on in!”
Is there still friction?
ANU:
I think it has certainly improved. I'm sure there's a market by market view of this, as is true in everything in healthcare. There are some hospitals that have basically determined that they have no choice but to bring in more midwives. By weight of the economics and the lack of OBs, in general. Medicaid has done a big policy push in the direction of expanding the midwifery workforce and coverage for midwives and things like that.
The mainstreaming of midwifery care has happened by force of a range of things converging. It’s in the patient-consumer zeitgeist. People have heard stories and read about the Black maternal health crisis and that has elevated midwives into the public consciousness. People a re learning about the limitations of our very medical model of perinatal care and how no other country does it like this. Patients are more educated on all of it (I wouldn’t say that is universally true across the country, but it is true in many parts of the country.) We have certainly evolved.
“People are learning about the limitations of our very medical model of perinatal care and how no other country does it like this. Patients are more educated on all of it… We have certainly evolved.” — Anu Sharma
At the physician level, it depends. Often [a physician’s] comfort level in working with midwives depends on whether they have ever worked with midwives. There are OBs who have trained alongside midwives and they understand the complementary skill sets and why working together is better. Then there are some who just haven't had that experience, they think midwives do not have adequate clinical training, and they assume they are going to be on the receiving end of a patient who was attempting a home birth and not well supervised. So it depends on the physician and their understanding of how midwives work (at Millie, we only have Certified Nurse Midwives who are highly clinically trained in physiologic birth and a broad scope of women’s health).
MOLLY:
What is the state of midwifery training these days? Are you seeing enough people training to be midwives to fill in obstetric gaps? For example, with how OBs are leaving states where abortion access is limited/criminalized or how physicians are choosing other specialities instead of obstetrics, is that loss being matched by midwifery training? What are we actually looking at 10 years from now?
ANU:
There is a Medicaid led push. Medicaid, disproportionately, is a big payer and they cover the populations that are disproportionately affected in terms of negative outcomes, oftentimes people of color. With the Black maternal health movement, intersectional work was on the agenda. There is a state tracker available through The Commonwealth Fund to see what is going on and different initiatives to expand access to midwifery care.
So there is an attempted expansion of the midwifery workforce. There is a real desire to do it. BUT, [what programs/schools] are graduating midwives? UCSF closed their midwifery program and created a PhD program. Why did they do that?
Do we need more midwives? Yes. Do we have a pathway for training more midwives? Unclear.
Overall, there is policy intent, but I'm not sure it's translated into changing the total numbers or integrating midwives into the workforce. There are also various other limitations that have to be overcome. In some states, midwives need to have physician supervision, they cannot practice autonomously. Or coverage availability is not on parity from a reimbursement perspective. So, even if you have trained midwives available, can they actually practice autonomously and get paid?
“Do we need more midwives? Yes.
Do we have a pathway for training more midwives? Unclear.” — Anu Sharma
You have this scenario where it has become incumbent on midwives to take up the mantle of organizing themselves and pushing for change and fighting the system. Relatively few markets have things like Millie (in New York, there is a company called Oula). In most markets, midwifery care is only available though out-of-network community practices who offer home birth or birth center-based care outside the hospital. Very few have gotten to a place where they have insurance coverage or admitting privileges at hospitals. There are all kinds of barriers even beyond the financial barriers, and the coverage. Those challenges are real.
That's the state of midwives now but we are slowly adopting them nationally. This is something we consider as part of our own market selection process.
MOLLY:
Back to the question of mom-centric perinatal care, I think one of the things that resonated in the The Unexpected Risk of Motherhood piece, came from a place of “there has to be a better way of doing this”. In so many ways, we have been programmed to accept that, in motherhood, there is an expectation that self sacrifice is just part of the process – that’s what motherhood is and we have to accept it. But then having someone point out it doesn't have to be this way is a helpful wake up.
In the space of perinatal care, now we have to ground this wake up in the context of constraints. We cannot say “midwifery-led care will solve everything!” or “let’s go open a Millie clinic in Alabama” because Anu is going to remind us, “guys, that's not gonna happen.”
ANU:
It will not work.
MOLLY:
That’s important for the next stage of the conversation: Why won't this work?
The question highlights what needs to change to break through the constraints. Everyone should have access to care that centers them, healthcare providers who trust them in their own bodies, services that provide emotional support and wraparound services… but that is not going to happen right away. We have a lot of work to do.
I can’t avoid this cliche – it's a marathon, not a sprint. We have to be really reasonable and realistic about the speed to affect change. We're doing the work so that our daughters, and our daughters, daughters, can have a better world.
What are the ways to keep moving this forward?
ANU:
[For those of us founding women’s health companies], we are still very much in the phase of the pioneers. We are beating down the bushes and carving out the path, and then, hopefully, making a certain level of progress so that people behind us get a little bit further, maybe learn from those early lessons.
“I don't know if we will succeed in reaching all 50 states. It's a little early to say that right now. But, I think we can certainly take credit today for having tried and made a lot of progress.” — Anu Sharma
Women’s health is a nascent category. It’s a little early to declare winners. But that’s what capital can solve. It often sits on the sidelines until the time that the path becomes so clear that they’re willing to pour money into it – but I’m personally really happy to see more women investors stepping in and new forms of capital emerging. But overall, the capital formation is still happening, especially at the growth stages.
We have to pave the way for the solution. Pave the way of figuring out how to work the system. Pave the way of the capital. Pave the way of demonstrating that it's achievable so that other people have it easier.
We're making forward progress. But, yes, the constraints are real. We have to work within the system. We recognize there's some markets that are just not a good fit. You have to find the right investors. There is a team of people who believe something better should exist in the world and are fighting to make that happen; trying to build on their successes and finding the champions, to take it further. I don't know if we will succeed in reaching all 50 states. It's a little early to say that right now. But, I think we can certainly take credit today for having tried and made a lot of progress.
MOLLY:
The image that just came to mind is Oregon Trail pioneers. Women’s health startups today are the ones who are fording the river and dying from cholera. But if you fast-forward 150 years, you can take a plane and grab a coffee in Portland, no oxen required.
ANU:
Yeah. And in ten years, will what we're doing now become more ubiquitous? Maybe, if we make enough progress right now. But it's really hard to know that.
MOLLY:
Would cuts to Medicaid set everything back? In terms of economics of perinatal care, midwives, access, etc?
ANU:
Well, [Medicaid] pays for 42% of births and is the only coverage option for maternity care in many communities. It’s not clear if the Medicaid cuts will impact maternity care – if they do, it will be quite devastating and definitely not compatible with the desire to see a “baby boom”. I think it’s unlikely because it doesn’t make sense politically.
MOLLY:
Do you feel like the general backslide in the political landscape (in terms of women’s health and views on motherhood) will make the constraints tighter? Or do you think things can keep moving forward?
ANU:
That's a hard question to answer for the following reason. Even in terms of the Trump “baby boom”, I was being interviewed about it the other day and I kept explaining that it's just a ridiculous idea. Given everything that we have discussed, the question is why don't we have more babies? an answer is because you made it completely unaffordable AND we don't have the healthcare infrastructure.
[Read Anu’s interview HERE]
Even from that perspective, it is an interesting time. ACOG has recently, nearly 100 years later, created a new prenatal care guideline, which for the first time acknowledges that a one-size-fits all approach should be replaced by something more patient-centered, that also acknowledges that maternity care is also about the psychosocial & other support that people need beyond clinical care. Politically, there is also a desire to see birth rates rise with talk about expanding coverage for fertility care to improve the birth rate in tandem. Then is a fair amount of capital moving into women's health. There are real innovations and companies moving things along. There are many reasons to be optimistic.
“ACOG has finally, nearly 100 years later, created a new prenatal care guideline, which for the first time acknowledges that a one-size-fits all approach should be replaced by something more patient-centered and also acknowledges that maternity care is also about the psychosocial & other support that people need beyond clinical care.” — Anu Sharma
There are also reasons to not be optimistic. There's just all the other stuff. So it's hard to say. I don't know if we're moving forwards or not. In some ways we are, but in other ways we're still incredibly challenged and now we have different headwinds. It's an interesting time.
MOLLY:
We could probably talk through the million ways to better support families so that they might actually want to have a baby (or more babies).
But even at the healthcare level, the level of who is providing prenatal care? Or just focusing on the most basic question – who is catching the baby? Even if all you want is more American babies (and you do not care about the incubator) you still need to consider, who is catching the baby?’
ANU:
I think, at the end of the day, that is really the headline – who is catching the baby?
Is it a midwife? Is it an OB? Why is it an OB? Why is it a midwife? Are there enough of them? Why don't we have enough of them? What does it take to have [a stable obstetric care infrastructure] in the modern era?
These are invented problems. They can be solved. We just have to decide to solve them.
There are a range of other great examples of ways to deliver perinatal care that centers the birthing person and their whole experience and reducing stress during this window of time. I’m interested in and exploring the full range and had originally contacted Anu with eyes towards having to have a more in depth post about solutions in this space but this conversation with Anu felt especially relevant and urgent to share bc it offered a perspective I had not even considered as one of the headwinds that any change in this space is facing.
As I often write — so much of this substack is my thinking out loud and the learning process along the way. I’m not a concise person but I will eventually synchronize all of this!
I have to admit, when I started reading this and saw that beautiful picture, I immediately thought "oh wow, another boutique midwifery practice for privileged White moms!" As a midwife whose patients are mostly Black and Brown and on Medicaid, I feel irritated on their behalf for what little attention is given to their experience of birth. This shows up in higher C-section rates, lower VBAC rates, less access to doulas and fewer calm/gentle birth experiences like waterbirth. I work at an FQHC and catch babies in an urban hospital. There is one hydrotherapy tub for like, 20 rooms. And the plumbing is broken (one water temp: very hot!) so I literally spent my last call shift dumping ice in a tub to cool down the water so my patient could use it. Congrats to Millie for pushing the envelope on what is possible for prenatal care/birth. It sounds different than what I'd imagined. So kudos!