Call The Midwife
As maternal mortality rates continue to persist in New York’s hospitals, hybridized models of care are emerging.
By Annie Abramczyk
Two nurses held Emily Yianilos down during a contraction and gave her a Covid-19 test. It was January 2021. She had labored at home for three days. She was seven centimeters dilated and in active labor by the time she arrived at Manhattan’s Lenox Hill Hospital. Her birth plan disintegrated. “I realized what I wanted didn’t matter. All of these things just kind of happened,” she said. “The doctor made the decision to perform surgery, and my body just gave up.”
“It was the saddest day of my life,” Yianilos recalled.
Yianilos left the hospital a few days later with a sheet of paper listing postpartum depression symptoms, massive hospital bills, and a baby boy.
Lenox Hill declined to comment on forcibly testing for covid during a contraction.
“I wasn’t even able to say the word trauma because I didn’t even feel entitled to using it until months after therapy,” she said. She was supposed to be happy. She was supposed to be grateful. She felt privileged to have had a healthy child in a hospital.
Yianilos was “sewn up and sent home” to Astoria, expected to nurse and bond with her new child while recovering from emergency cesarean surgery (C-section). Unprepared for postnatal anxiety and depression, Yianilos “was drowning.” And a few months later, Yianilos found out she was pregnant again.
This time, she hired a midwife, and everything changed. “It was so much more of a conversation. I was involved,” Yianilos said. They let her eat during labor, rest, and most importantly, did not impose a timeline on pushing. Yianilos delivered a healthy VBAC (vaginal birth after cesarean) baby — something that is almost unheard of for previous emergency C-section mothers; doctors, unwilling to risk complications, typically encourage having another C-section if a patient had one with their first baby. Her birth plan was respected. This time, her baby wasn’t rushed to the NICU. Yianilos held her healthy baby girl.
“Honestly, it really was a matter of life and death. I truly believe that I would not have mentally survived another traumatic birth. I would have ended up in some sort of facility,” Yianilos said. “The care, the love, the encouragement, the firmness, and the security was a night-and-day difference from my first experience.”
Yianilos had considered a midwifery model for her first birth but refrained. “I kind of assumed that I would need to lay flat on my back. I was worried about money. I didn’t think insurance would cover it. I had two different voices in my head: don’t use drugs or be knocked out.” And she’s not alone in that zeitgeist.
“If it were simply a ‘medical care’ issue, then the U.S. would have the lowest maternal mortality rate in the world, wouldn’t it?” Michael Marmot, Professor of Epidemiology at University College London, Director of the UCL Institute of Health Equity, and Past President of the World Medical Association, asked in his book The Health Gap. “The U.S. spends more than any other country on health care. Arguably, it has the best obstetric care in the world, but it does not do very well… In fact, 62 countries have lower lifetime risks of maternal deaths than the U.S.”
“Let that one sink in a bit,” he wrote. “No woman should die during pregnancy and childbirth.”
But women are dying — at an alarming rate. The U.S. has the highest maternal mortality rate out of any industrialized country in the world, with a steady increase since 2000. Maternal mortality is “death while pregnant or within 42 days of pregnancy,” according to the World Health Organization. Maternal mortality rates had a massive 40 percent increase between 2020 and 2021. 1,205 pregnant women died in the U.S. in 2021, according to the CDC. Some of the deaths were caused by COVID-19 complications, but many were preventable.
In New York specifically, 78 percent of the deaths in 2018 were preventable, and 100 percent of the deaths caused by hemorrhage, mental health conditions, and cardiomyopathy were completely preventable, according to a 2022 report released by the New York State Department of Health. Furthermore, racial discrimination is responsible for almost half of these deaths. Discrimination was “identified as a probable or definite circumstance” for death in 46 percent of all pregnancy-related deaths, according to one release.
Faced with this grueling reality, a growing chorus of mothers, advocates, policymakers, and even medical professionals — long resistant to birthing alternatives — are calling for a different approach to perinatal care. But will the rest of the healthcare system listen?
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20-something miles away in northern New Jersey, Amanda, a mother of two, had almost the exact same experience as Yianilos: she started with a medical birthing model in New York City in 2021, had a harrowing delivery, and switched to a midwifery model at a hospital in New Jersey for her second birth.
“My second birth was not traumatic. I didn’t know that childbirth didn’t have to be traumatic,” Amanda said, describing her second birth. (The subject didn’t share her last name out of privacy concerns). “My midwife brought a sense of zen and calmness to the room,” she added.
Both mothers strongly advised friends and parents-to-be to use the midwifery model for their first birth. Yet a common hesitancy they encounter, they said, is that the midwifery model of birth wasn’t what they envisioned when they imagined labor and delivery. There seems to be a prevailing status quo in the U.S. when it comes to birthing practices. “People have a lot of different impressions when they hear the word ‘midwife.’ For some, especially if you are in Europe, they immediately associate a midwife as the go-to medical specialist to deliver your baby. But for many, especially in the U.S., you may conjure up an image of a nurse from the medieval times or, more commonly, you might confuse the term with a ‘doula,’” Katie Sigler, an NYC based Certified Midwife nurse wrote in her blog post.
Midwives are licensed health care professionals trained to provide expert nonsurgical care to women from puberty to menopause, including pregnancy, labor, and delivery, according to Oula, a modern maternity center in NYC. Nurse midwives working at hospitals in New York City are certified nurses with additional rigorous midwifery training, some with master’s degrees, according to the New York State Education Department.
But the midwifery practices in New York City are evolving to fit the specific needs of birthing persons in the city. In some states, midwives mostly attend home births or work at birthing centers. In New York, midwives and nurse midwives practice regularly in hospitals, creating a hybrid medical-midwifery model of care. “The midwifery model is expansive and encompasses different types of midwifery. For example, homebirth midwives versus hospital midwives require different certifications, and their practices can look very different. At its core, midwifery care is about really prioritizing the mother and baby,” Carson Meyer told me. Meyer is a celebrity doula in L.A.
Midwifery is an ancient practice. The word “midwife,” derived from old English, literally means “with women.” A labor and delivery doula is a non-medical member of the birth team who assists the birthing family during birth. Doulas can also provide support through all stages of the perinatal journey. Christine Gibson, a New York-based doula, mother, and childbirth educator, believes that these largely-accepted ideas of birthing in the U.S. are largely perpetuated by Hollywood movies and TV shows. “We see women screaming, rushing to the hospital the minute their water breaks, laying on their backs pushing,” Gibson said. Hollywood doesn’t show the hours of labor, the different birthing positions, and the non-emergent births.
In fact, most births aren’t emergencies. In Dr. Neel Shah’s podcast “Here For Her Health: Destigmatizing Women’s Health Issues With Neel Shah,” he often talks about the fact that labor and delivery floors are the only floors in hospitals that are made up of perfectly healthy people. Giving birth is naturally a part of life. So why do hospitals in America treat birth like an emergency or sickness?
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There are major inequities within the healthcare system regarding how people are treated. Black women are currently three to four times more likely to die during childbirth than white women, according to Pregnancy Justice, a leading pro-bono organization for social justice issues involving or related to pregnancy. They make up half of the women dying during childbirth in New York City, the result of systemic health inequities and historically racist medical practices, advocates say. Oftentimes, these statistics worsen the situation rather than help it, advocates say. “These statistics can perpetuate harm,” a doula, who trained at Ancient Song NYC, a national birth justice organization, told me. “Statistics are dehumanizing. They raise cause for further intervention in hospitals regarding caring for Black mothers.”
For example, many hospitals in New York drug-test urine on pregnant Black mothers without consent. This can lead to the separation of families, subjects said, and perpetuate harmful forms of oppression.
“I strongly feel that the Black maternal health crisis is not just something that needs to be solved by Black people alone,” Gibson said. “Stop going to these hospitals that are doing this to people. Whenever a white person divests from the system, you are helping boycott these racist providers just by doing that.”
The discrimination extends beyond the increased propensity for medical intervention and affects how Black parents are treated by healthcare providers. Sources spoke about Black birthing partners referred to by doctors as “baby daddies,” offices questioning the validity of insurance, and care providers unfairly flagging ultrasounds for obesity. “It’s extremely hard to undo cultural bias. There’s divestment from caring about Black women in labor and delivery rooms,” Gibson said.
The current top-down care systems, which give power to the hospital lawyers, administrators, obstetricians (OBs/ OBGYNs), and nurses all over the birthing person, fail to prioritize the health and safety of the birthing person, especially for people of color, according to educational group Evidence Based Birth. The “evidence-based practice gap” in current medical systems “is astounding,” according to Lisa Greaves Taylor, the CEO, and founder of Birth Matters NYC, a doula training company and perinatal education source. “There’s a long withstanding doctor-knows-best mentality that I see as a doula when working in hospitals,” Greaves Taylor noted. It takes roughly 20 years, she said, to implement entirely new practices like informed consent, trauma-informed care, and anti-racism training in medical systems due to the years of schooling and older generations of doctors with outdated methods who still work.
“When you’re in labor, you’re in an often vulnerable and sometimes non-verbal state. When things get very intense in labor, it’s important to have someone who can help you speak up for yourself,” Greaves Taylor said. That’s where doulas and midwives come in: the midwifery model centers the care and power on the birthing family, reminding patients that they have rights and should exercise them, according to Greaves Taylor.
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“The biggest piece of advice I have with advocacy is to remind people that you are still autonomous,” Megan Fendt said while driving to work one Thursday morning. “But speaking up for yourself is a really hard thing to remember when you’re in labor.”
Fendt was a registered dietician and diabetes educator — until she witnessed her sister give birth. “Her OB was a complete douche, as nasty, mean, and inappropriate as a health care provider could be,” Fendt recalled. “At that moment, I was like, ‘I have to say something. If this is what’s happening, I have to do better.’” Immediately after that experience, Fendt changed careers. She is now a midwife at Oula, one of the city’s first collaborative care groups.
Founded in 2019 in Brooklyn, Oula uses a “middle ground approach” to maternity care, combining the best of obstetrics and midwifery for an evidence-based personalized pregnancy experience. According to its website, Oula’s mission is to set “a new standard for pregnancy that unifies modern medicine and human intuition,” which they tag as “collaborative care.” That means all babies are born in hospitals. Certified OB-GYNs, midwives, nurses, and doulas work together.
“Our patients tend to heal better with our care because we take the time to get to know things about them. We care about their family, where they live, and if they have enough money to get food. It’s the little things that make people feel like you know them, and that makes them trust us,” Fendt said. Fendt attributes one significant difference between medical and midwifery models to approaches toward care and time.“I just don’t think that doctors are trained to sit down and chit-chat with people. It’s just like, ‘Do your clinical care, get your history, do your physical, and get out of the room.’ ’Cause they don’t have time.” Fendt said.
“There are a ton of wonderful things about OBs: how they care for people, their wide skill set, they’re surgeons, they’ve been through more school,” Fendt continued. She believes there are many redeeming qualities to having obstetricians on your team. “But they’re not trained the same way midwives are, which is approaching birth and pregnancy and many life cycles as a normal thing,” Fendt added. It’s one of the reasons why newer models of collaborative care like Oula has been so successful — medical intervention is only used when absolutely necessary.
In comparison to perinatal healthcare systems in place around the world, New York’s hospitals are rated among the worst in perpetuating high-pressure birthing environments, often resulting in the need for more medical intervention. “It’s evident that there’s a trend toward more and more intervention, especially in the increasing propensity to induce everyone, even when it’s not medically necessary, ”Greaves Taylor said. Medical induction is when healthcare providers use methods such as rupturing the amniotic sac or injecting the hormone pitocin (a version of oxytocin) that causes the uterus to contract, according to the Mayo Clinic. Some New York City Hospitals have medicinal induction rates as high as 34 percent and amniotic rupture rates as high as 36 percent, according to the New York Department of Health. New York City hospitals are over-zealous when it comes to induction, according to Greaves Taylor.
“Usually it’s due to someone being 40 weeks,” doula Christine Gibson added. “There’s such a high demand of people trying to give birth. They don’t want that backlog of people laboring. Decisions are being made for what’s best for the hospital and not for what’s best for you,” Gibson said. “When you enter for an induction, you aren’t leaving until your baby is born. They’ll do everything, including forcibly breaking your water.” During labor, in many medical models, women aren’t allowed to eat or drink anything except ice chips and are instead given an IV, due to fear of complications with anesthetics.
The high induction rate, coupled with pushing limits in hospitals, correlates to the fact that New York has one of the highest C-section rates out of the U.S., with over 34 percent of live births resulting in C-sections in 2021, ranking number 7 out of 50 states, according to the CDC. Additionally, on average, C-sections in New York City cost around $24,500 — a $7,000 difference compared to the average $17,500 cost of vaginal births, according to the Healthcare Cost Institute.
Furthermore, private midwives and doulas are rarely covered by insurance, perpetuating the economic inequities in healthcare. There are some nonprofit organizations, but many people pay out of pocket for their birthing team.
“I hate to look at it this way, but it’s a business. The hospital is a business,” Yianilos said. “They have a push limit cause they need to turn over the room. They make you pay for a private room. I had just had major surgery, and I had to pay for a better room that was the size of my bathroom at home.”
Afterward, Yianilos received a hospital bill of around $800 extra a night for recovering in a private room. Amanda was put in a shared, small postpartum room. Both Yianlos and Amanda gave birth in city hospitals with strict COVID-19 policies on visitors in place. The hospitals restricted visitors and the number of people in the rooms. And yet, required them to recover sharing rooms with roommates. “The American healthcare system is a joke,” Amanda said later.
“When I went through childbirth, my whole world was flipped upside down,” Amanda remarked. “It’s really sad because it was very traumatic. I had no one to talk to. I felt alone. I had a really difficult recovery, but no one had prepared me for that.”
“That’s the keyword: feeling alone.” Rensa Brunson, a mental health therapist, and doula specializing in postpartum care, told me. “You feel like you have to keep this smile on your face because you have this new baby. You’re dealing with a living being that’s being formed and fashioned and developing into a new human,” Brunson added.“Parenting looks easy,” she continued, “new parents go to the market, and you see the mom and the baby. You don’t think about what it takes for that mother to get the baby in the car seat.”
“Everyone goes through postpartum. It doesn’t have to be postpartum depression. You are going to go through some sort of postpartum. Being able to talk to someone– a therapist, a doctor, a friend– is key,” Brunson said.
Postpartum mental health is overlooked in accounting for maternal mortality, advocates say — the statistics only pull from 6 weeks postpartum. But postpartum depression and anxiety can last much longer than 6 weeks. In fact, 52 percent of maternal deaths in the U.S. occur postpartum, and 12 percent occur after the 6-week, or 42-day period, according to The Commonwealth Fund.
After Amanda opened up about her experience to other moms, she discovered she was not alone. Many people had alarmingly similar experiences. The feelings of isolation, depression, and anxiety were exacerbated living in the city as a new mother during a pandemic. “I’m very much of the belief that it needs to be talked about so things change. I don’t think it’s talked about enough,” Amanda said.
In April 2022, New York Governor Kathy Hochul dedicated $20 million in the state’s 2023 budget to “addressing the structural and institutional inequalities in the healthcare to create a safer birth experience for all mothers and families across the state, including those who are undocumented,” explicitly listing closing racial inequities as its goal. Hochul’s plan will also expand postpartum Medicaid coverage from the current 60 days to a year after giving birth, hopefully leading to more equitable health outcomes state-wide.
In the meantime, New Yorkers will continue to have babies. For new parents, awareness and advocacy remain potent weapons to combat injustices in perinatal healthcare systems. “I thought about writing a short film or a pilot about my experience,” Yianilos said. “There’s a lot of stuff about parenthood out there, but when you look at it, a big part of giving birth is still just so taboo,” Yianilos added. “It’s about getting the word out there somehow,” she said. “So many new parents go through this and feel guilty that their experience isn’t like the ones they see in movies.”
“I would be remiss if I didn’t openly share what I went through for two reasons: to help educate people that it does not necessarily have to end up like this, and to let people know that they are not alone.”
