Ep 64 Jane Houston on midwifery challenges and disparities from Scotland, Zimbabwe, NZ to Florida in USA (PART 1)

Ep 64 (ibit.ly/Re5V) Jane Houston on #midwifery #challenges and #disparities from #Scotland, #Zimbabwe, #NZ to #Florida in #USA (PART 1)

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Ever wonder about the world of midwifery, its challenges, and the systemic disparities in maternal care? Join us as we delve into these topics with Jane Houston, a midwife who has worked in Scotland, Zimbabwe, New Zealand, and the United States. Jane weaves her compelling journey from her family's healthcare background to her passion for serving birthing families. She shares her insights about the stark differences in midwifery education between Scotland and the US, and her experiences working in both hospital and community settings. 

In our conversation, Jane transports us to scenarios around the globe and back. She recounts her stint in Africa, a place where she witnessed uninterfered births and marvelled at the resilience of the women in the community. Jane also narrates the pivotal role played by Joan Donnelly in saving midwifery in New Zealand and the empowering process of midwives self-identifying and catering to clients who share their experiences. Together, we navigate the complexities of providing comprehensive midwifery care in a capitalistic world, and the increasing trend of C-sections in the United States.

Reflecting on her vast experiences, Jane expresses her concern about disparities in the healthcare systems she has observed, particularly in the US where she identifies a disempowerment of women and a lack of understanding of midwifery care. Beyond the challenges of obtaining a master's degree, Jane emphasizes the need for diversity in the midwifery profession and the importance of personalized care. Join us to learn from her journey, her views on improving midwifery practice, and her contributions to various research and quality improvement projects in the first of a two part conversation!

Transcript

Speaker 1: 0:15

And welcome to Through the Pinard, your conversational podcast talking to midwives around the world about the research they are doing to improve midwifery practice. This research can range from small quality improvement programs and projects to those starting partway through or just finishing their postgraduate studies, and to those that have been there, done that and got the t-shirt. So settle back and enjoy the conversation and remember you can continue the conversation on Twitter after you finish listening. For the first time in this podcast history, we are having a double episode because we covered so much information, so we're going to break it just before Jane starts talking about her DMP studies. However, I think you'll find that she has led a very interesting life, so stay tuned for part two, where we continue talking more about her career, her studies and being a midwife in America. Thank you very much for joining me. As per usual, can you introduce yourself please?

Speaker 2: 1:25

Ah well, thanks Liz. My name is Jane Houston and I'm a midwife, so there you go. That's what I like to see An old, wise woman.

Speaker 1: 1:34

An old, wise woman. So how did you get into midwifery?

Speaker 2: 1:38

Well, I used to say I'm from a big family, but I think it's Pints, pints we've come from.

Speaker 2: 1:44

Yeah, I contextualized in it. So my parents were both in healthcare my father was an orthodontist and my mother was a registered nurse and then a lot of my siblings are in midwifery, obgn, pediatrics, things like that in healthcare. So healthcare was really a calling for me, not specifically initially a midwifery, so at that time, because it was quite a long time ago in Scotland I think 40 years ago what Really Wow. I must have been five, yeah, very young, when I first went to nursing school and actually and talking a lot now about over medicalization the first births I saw were not ideal, let's put it that way. I was forced into a room with a couple maybe I didn't know, and it wasn't the earth changing, life changing event that I kind of thought it would be, because at home we talked a lot.

Speaker 2: 2:48

Mummy breastfed all of us and started breastfeeding in the 1950s when it was actually normal. Unfortunately, with the advent of formula she had four of us born in the 60s, which was it was very important for us. So it was her ethos about the importance of if you're able to physically breastfeed your own child, talking about the importance of that. So that's really the culture I grew up in In my family was the culture of normal birth, listening to women breastfeeding, having family support for all times. I'm really valuing that and knowing how that is and how can you best bring that to your families that you work with.

Speaker 2: 3:31

But for your point at that time in Scotland where I was born, it sounds very base of me. But the government was still actually reimbursing and they do again. Thank you, scottish government. It was actually free at the point of not having to pay fees. I still had to buy books and things, but it was another qualification. So when I finished my nursing degree I worked for a couple of years and then a lot of my friends at that time. It was still normal. You just automatically went and did midwifery and actually then it became a revelation that this was actually where I was supposed to be, especially when women are at that point in labour with the birthing family. That's really where I feel called to be. So that's really where my I said my birth story, where my birth of midwifery story really begins, was in 1990 when I entered midwifery school and found my passion of my life. So that's where we're kind of jumping off from right now.

Speaker 1: 4:43

So where, what areas did you work here when you were in Scotland? So I know that you've travelled a bit and you've kind of globetrottered a bit. So when you're still in Scotland, straight out, where did you work in the community, in hospitals?

Speaker 2: 4:56

So another great question so in the 90s? Well, so, in Scotland, for those of you who are listening in other countries we have what's called universal provision of healthcare, which means at the point of the patient meeting with you or the client, whatever you want to call them the care is provided for free, based on taxation. So in my training or education at Glasgow Eastern College, we mostly worked within the hospital, but also community. So we had to work in all areas. You know we're talking about the neonatal intensive care unit, labour room, postpartum, anti-partum and community. So they were all very, you know, very. It was a very set set of objectives because it's based on universal provision everyone is able to access, and we'll talk more about this, about the issues.

Speaker 2: 5:56

I currently live and work within the United States and looking at that model, trying to get clinical sites. This is a constant struggle, but so it was all pre-packaged. So I knew on this day I would be in this part and some of my colleagues did actually do births at home, a normal setting, but at that time that I did not experience that. I did a lot of community midwifery, working with birthing families and some domiciliary where they come in. They had their name midwife and they knew you and then but mostly it was very medicalised I'd meet a family. You know, at the point I'd never. You know, I usually hadn't met them before unless I'd actually looked after them, say in the anti-partum unit. So most of the time these were new families in labour. So that's really what it was like and that was typical at that time. And you go through all the different kinds. Especially, I found it really helpful Because my first placement as a, when I qualified, was actually in the neonatal unit which people out. Well, that's weird, that's a weird role. Actually it's not. You know, in the UK still.

Speaker 2: 7:09

Basically, the midwives offer all the care. They do all the high risk scanning, they run the high risk clinic, they run all the clinics, they run the midwifery unit, they go and look after you at home. It's very, it's just a very good system and I see the importance of community care when you don't have any, which is where I'm currently work. There's, you know, we give somebody a piece of paper so they can learn to breastfeed. I don't think you learn to breastfeed a new baby by reading from a piece of paper. But the lack of community resources here is something. That's it's I've tried to work on for a long time, but that's getting ahead of the story.

Speaker 2: 7:48

So basically, basically I did what's called a typical education program for midwifery. It was 18 months, it was called a diploma in midwifery and that that was good in the sense that you know you do have to know about medicalization and caesarean sections and interventions. But compared to normal and I don't like the word amnol, but let's say medicalized it was very over to the side. So because I didn't really see a lot of what now I know is, you know, a normal experience for most women that you can, can help with, because I didn't really have that experience at all. It was very. There was a lot of interventions. Maybe that could have been avoided if women had actually been listened to.

Speaker 1: 8:39

But then we kind of because the medicalization has changed so much. When we're talking about normal birthing experiences. We're not. It is about induction. It is more so about caesarean section. It's not about normal vaginal or physiological birth. And I think that word normal is needs to change in our understanding, because whilst it's not normal vaginal birth, it's a physiological birth, because the rates of induction are no over here, are ridiculous, and caesarean sections are globally increasing. That what is normal has changed.

Speaker 2: 9:14

Well, that's right, and I talk a lot about how to be normalized the experience for the family. How do they still feel empowered, how do they have, hopefully, the birth experience that they mostly desired? And, to be honest, where I work now, this will probably blow your mind, but we have a very high risk population in North Florida. Our C-section rate for primary transverse cesarean is 14.9%.

Speaker 1: 9:40

Oh, lovely.

Speaker 2: 9:43

So I'm very excited about talking about that. How do we achieve that? How do we allow the patients to come back? How do we work with the watchful waiting and the careful monitoring and making sure that women that are?

Speaker 2: 9:59

You know, unfortunately, as you know, a lot of our clients and I am sure it's maybe the same where you are, liz we've got issues, chronic hypertension, and I have 20s up to early 20-something-year-old people with chronic hypertension. There may be. They're a little overweight, they're already starting pregnancy in a high-risk setting which maybe 30 years ago there was a lot fewer. It's like if you think about your seasonal diabetes when we were at school, it's like, yeah, it's not very common thing, oh, but it is now. But about 14% of our patients now will be identified as having carbohydrate intolerance.

Speaker 2: 10:40

How do we normalize those experiences without taking away the essential physiological elements that will enhance the family's ability to have a normal experience? That's empowering, because this is part of what I also talk about is joy. You know, we've got so many of our younger folks with the pandemic and, before that, the anxiety issue, and I think that's worldwide. But the epidemic of anxiety, when you're anxious, when you're starting pregnancy as an anxious person, maybe you're not the best supporter, maybe you're a solo parent, maybe you've got no money, you know.

Speaker 2: 11:15

We then know the social determinants of health are much more important, and I tell the patients this all the time. We may be great, we may be the best metwifes you've ever met, or the best OBGYNs or the best whatever, but the most important thing is your cultural aspects, what you're bringing to the table as a human and you've got to this part of your journey so far. How can we enhance that and help with you coming to the understanding of what would be a normal experience for you, so that you're going to feel the essential joy and the love for your baby? Because if you're not able to feel that joy I mean there's a lot of patients now that can't feel joy because they're depressed or they've got severe anxiety but starting out with acknowledging that that you know where are you in this life journey and how can we best help you to have a somewhat normal experience and become a successful family going forward.

Speaker 1: 12:13

Well, without that joy, you have increased chances of birth trauma, you have increased issues with bonding and attachment. You've got all of those and that's that intergenerational cycle that also starts as well. So, yes, it is that how do you make the most of, regardless of what model of care you're in? Okay, we'll come back to that. I know we're going to come back to that as we kind of progress through your career. So after how long did you spend in Scotland before you started then traveling, working as a midwife?

Speaker 2: 12:41

So well, that's another good question. So when I finished, there was actually a recession and there was no full-time jobs. If you can believe that qualified in 92, and there was no full-time jobs. I remember our professor coming in and said right, girls, and I made a joke about oh well, I see there's openings for domestic assistance, but there was no full-time jobs.

Speaker 2: 13:08

So one of my sisters was a long-term medical officer, objn provider, in rural Zimbabwe, in a lovely place about two hours west of Harare, and she said well, why do you come out here for a few months and help me? Because there's, you know, there's lots to do and I also, I mean I saw one. Well, I would term normal birth when I was in my training and I knew with the setting that was there. It was very rural, it was a hospital, but still there would be very exciting to actually observe normal birth and to be able to go there. So I went there with the understanding that you know, I worked in all the different areas, but specifically in maternity, to see what it was, and it was at the height of the AIDS HIV crisis worldwide. So that was another big challenge because, even though we knew about it and I can't speak to Australia, but it's, for example, in Scotland. If you knew that somebody had an infectious disease or an issue that needed to be addressed, it was very good that we had specifically trained providers that they would go to this clinic or that clinic. So you didn't really have the knowledge or the understanding of the impact of, for example, HIV AIDS. So we do know about 40% of the patients that I was caring for were HIV positive, which nowadays it just sounds stunning, but many of the actual providers, a third of the population, the general population of Zimbabwe were also HIV positive. So it was a big learning curve learning to live, learning to live in more basic means, you know, not having things, not having running water, being able to.

Speaker 2: 15:08

How do you assist women? And we would only see the rural women. They would only come in if they'd been identified as first-time parents or grand maltyporous with previous issues. Because most women there we would not hear from, there was no care, they wouldn't come in. I mean that's fine, that's. I mean you aren't be supposed to birth at all. I mean that is where we should all be having our babies if all else is the same.

Speaker 2: 15:41

So I went there for a good few months with my sister and it was very challenging but it was really life-changing for me. I actually saw birth that was not interfered with, the strength of women, the community of women looking after each other. And they were called the waiting mothers. And I'd say, who are the folk like? Because we had a big compound, so we had the compound mom base, the cows there which always invade the compounds. They'd have these big gates, they had a big sandy floor around all the wards. So they say, who are these people that are sweeping the courtyard and keeping everything clean? Oh, that's the waiting mothers. They have to do that so that they can justify staying here, because they'd come in from their rural village, you know, a few days before. They thought their baby was coming so they could stay, but they also had to offer services to be allowed to stay.

Speaker 2: 16:34

So I'm just seeing the capacity of humans to birth normally and very normally, despite everything, and that really was life-changing for me, knowing that we don't need to help, we're not there to help, we're just there to be. Is it a con to it? I don't know what the right word is. How do we best support them? And I think that was as a young midwife, understanding that trying it's not about us. That's the thing I teach now within a residency and I'm getting ahead of myself. But my point is that trying to teach young providers is not about me. It's how do I hear from my patient or my client? How do I understand what is the best thing, because it's maybe not the best thing for me, but that's not about me how do we achieve this thing and how do we support and enhance their ability, Especially when you're sick, you've got other health issues, there's no water, there's no food, there's dangers it wasn't, it was quite a dangerous place as well and how do you deal with all that and also have a birth that's life enhancing and joyful and great, and just to see the joy there and the appreciation and the understanding you know this is really good. I'm lucky.

Speaker 2: 18:08

I got to come here, I had the baby and they successfully birth and go off again within a few hours Back to their villages and they've had a birth that could be construed as something normal that they felt was really, really good. So that's what happened. And then, after a few months, there was the jobs. The health system seemed to be getting back on its feet again, so I took a job back at the place I had.

Speaker 2: 18:38

I was actually born there, so one of the midwives I was born there, so one of the midwives I worked with she'd actually been at my birth, so where I was born, and then one of my sisters also trained. There is no BGYN, but yeah, I was working within that setting and it was called the rotation, that's what it was called. I don't know what it's called now, but you went through again as a qualified midwife. You kind of rotated through anti-partum labor and birth room, postpartum NICU so I did all that again for the next couple of years. So that's what I was. That takes me up to, I guess, the mid-90s when I had another change in my career commitment in Scotland so I decided I was getting at she-feet. Now it's have to go on my travels again.

Speaker 1: 19:35

And that's when you ended up the complete other side of the world.

Speaker 2: 19:38

That's right down on there. Yes, hello, mike Next door. Yeah, so I was very lucky to be offered a job. For all the out there, new Zealand, cura, and beautiful, what a wonderful, what a wonderful country. And yeah, I went there as a well, I don't know, I got a job. I got a job as a midwife, so it was fantastic. It was just, I don't know, it's hard to explain.

Speaker 1: 20:13

How did you find the differences between the healthcare systems, between the NHS in Scotland and then the healthcare and specifically maternity system in New Zealand?

Speaker 2: 20:24

How long do we have? Okay, short version. Well, you know, actually the National Health Service was based on the New Zealand Aotearoa model, so I think it's funny when you ask that question. So actually that should be the reverse, exactly so, and so there wasn't that many differences in the sense that it's free at the point of access, which is great. So just no, probably I think 10 or 20 years before there was this groundbreaking midwife and I passed away. Her name was Joan Donnelly and I'm actually going to be talking about her in a few weeks.

Speaker 2: 20:59

When I got to Canada, she was actually a Canadian woman who emigrated to New Zealand and New Zealand Midwifery was in crisis in the early 90s and the patients were being told to choose a lead maternity carer, so they had to nominate. So of course, a lot of the doctors were horning in on that situation, because we do know, if we give reasonable care that women, because of all the oxytocin of pregnancy and birth, that they will become your client for life, if you're a reasonable person, when they first meet you. So midwifery was in crisis there and Joan Donnelly had this really incredible, this grassroot effort and you can actually her book's out of print now, but it's called. The actual effort was called Save the Midwife and she did. I mean she wasn't single-handed, obviously, but she was the person that really started off saving the culture of midwifery. So I was able to benefit from directly, from her work and her colleagues' work, that midwifery was becoming very strong, especially among indigenous and island women, midwives that were living now in New Zealand and being able to and I think it was interesting, you know, currently in the United States talking about racially concordant care, that these midwives were able to self-identify and look after a clientele that maybe looked like them, spoke like them, were indigenous or native people.

Speaker 2: 22:40

And also the importance of community care. Again, you know we have I don't know if they still have them, but they were called plunket rooms, like rooms that the family could go to, specifically the breastfeeding mum. They didn't need an appointment, it was in. You know there was a lot of them in Wellington, just so what? Have a meal, go to sleep? There's a midwife there, she can help you. But mostly it was the community of women helping other women, because there's a lot of immigration, so there's a lot of people that are not there with their immediate family. So those needs, you know, meeting those needs in very and very economically cheaper ways. You know.

Speaker 1: 23:23

Filling that cultural safety element.

Speaker 2: 23:25

That needs to be a part of that joy you need to feel safe, but also knowing that there's another responsible human being that can safely look after your little person that you've birthed. Because you know, having done this, and it's probably the same for you when you observe women that are trying to do this journey. So it's rather impossible, you know, to do that, as someone that comes from big families, had experience of siblings that maybe weren't the best supported by their partners, seeing the impact of community, proper community support and its grassroots. It's not like, it's not hard. This thing, this nebulous thing, what we're talking about is so simple. It's the antithesis of medicalization and saying birth is normal until proved otherwise. And I also bang on about this at work, just saying look, it's okay, just leave things alone, it's okay. It's okay to say this is okay, this patient understands the risks.

Speaker 2: 24:33

And it's not for me to say, you know, it's when people say what is your opinion about something? I said well, I don't really talk about opinions. I say here's some information. You know, I'm not there to say I mean, I told my twin sister I didn't think I was very judgmental Probably 20, 30 years ago, which was, in fact, I think you're the most judgmental person I've ever met. So that was kind of an eye opener. So I really try. And you know, talk about bias and healthcare like how do I? It's so hard Because you know you do have strong feelings and I'm not going to get into it here.

Speaker 2: 25:11

I don't think it's appropriate. I do have strong feelings about lots of things to do with healthcare and normal birth and things, but that's not my birth. I'm not taking your baby home. So I was like what happens to the baby after birth? I don't know, that's for you to. You're a stranger. You've got to come to terms with the restranger that's coming home, you know. And how have we given you the information? Just because I don't necessarily agree with your plan for your birth, that's not for me to say that. It's for me to say, well, you know, if you're willing to accept that, then that's up to you and that's the importance of informed consent, right? Well, and that's another how long have we got on informed consent?

Speaker 1: 26:02

Oh, that's a whole panel.

Speaker 2: 26:04

How do we I mean, you know, if you have a 15 year old person that's unexpectedly pregnant maybe it wasn't we do have a lot of our patients, unfortunately, are in non consensual relationships and that sounds ridiculous, but it's true how do folks in that situation, with all that stress you know they're a younger person and you know they've never had to make big decisions you know we have, you know we have patients, unfortunately, that have been trafficked and things like that how do they make it? It's fine for us to sit here while you're on informed consent. That's great. Everyone should get that right. We just rubber stamp. It doesn't happen. Everyone should get that. Everyone should get a norm worth. Is it the right term? No, liz, if you've got, that's a good question, you know.

Speaker 2: 26:51

So I had to give you a good example. I had a 15 year old. Her mom came in first visit. I'd never met her and the mother's obviously upset. Her 15 year old is pregnant and she's far too small. She needs to have a C-section I don't know where you are and getting the trust. That's a whole lot of other things we can talk about for 12 hours enhancing trust, relationships in midwifery and birth, because that's key if your client doesn't trust you that you're assisting their decision making but you can't really lay. How do you lay all that on a 15 year old or a person that's under stress and say, well, I'm sorry, that's your, your inform now. I told you the risks and the benefits and blah, but you've got to make that decision now and actually this young lady ended up having a wonderful normal birth and she's great, but you know, getting to that, if we got seen her that early and a lot of we have a lot of service patients here.

Speaker 2: 28:02

They've not had any care and maybe had one visit somewhere else and they're five centimeters and there's a problem. Or they don't speak English or or there's no coverage, they have no papers or you know they're undocumented people. And how do we, how do we suddenly, how do they suddenly, trust us to do this most intimate of things? And how do you inform consent? You know, with a translator, you know, if we have people of other languages, how do we know they're actually saying what they're saying? You know, are they actually presenting this or are they just saying something else? And that that would be a really interesting PhD, especially in Florida. It's extremely diverse. We may have patients that speak four or five different languages on the floor at any one time. How do we meet their needs? We can't even speak to them. How do we relay the fact that we want to do our best for them and they should trust us, and that's that's I'm thinking this is like really deep, but my mind is getting blown by your, by your perspicacious questions.

Speaker 1: 29:14

So it is that kind of there's the ideal world and then there's the reality of, once again, the fact that every person has to be treated. Every woman, every in this case child has to be treated individually for what is their situation and to be able to give them the care that they need. And if you can't pivot and adjust and able to adapt your care, then you're not going to be able to give the best quality care for that person, for what they need at that time. And that takes experience, it takes patience, but it also takes a willingness to be able to take the time to learn what that person is. And if you've got a language barrier, that makes it really hard and time.

Speaker 2: 29:56

You know, time in America is money.

Speaker 1: 29:59

Times everywhere. Everywhere is running out of time. The appointments 10 minutes. You get 20 minutes if you're lucky and you're meant to do everything in that time. You can't. How do you do comprehensive care in that kind of like when you're playing against the clock?

Speaker 2: 30:11

Well, I don't know, and I don't know if this is an appropriate time to ask you a question, but I had a revelation. I've had a lot of revolutions in my life. I'll say I'm an evangelist of normal birth now. But the whole idea that we lose money, so we're told we lose money, or any labor and birth, how is that possible when the most important part of the whole, well I think, well, maybe I'm mistaken but the sense of having an empowered family at birth and this joyful birth, but if we're not able to, I mean it sounds base, but no, the only time we get paid in the United States is seeing patients in the office. Right, so we can do it's called universal charge, say it's like two or $3,000 for all the visits the prenatal, anti-natal visits and then the postpartum. But how did that most important part, how did I get missed? Because when I'm in the labor room I'm not generating dollars for my office. But how did that? How is that not a charge? I do remember in New Zealand, if I'm not mistaken.

Speaker 2: 31:30

At that time there was a lot you know the community advice could access. You know, if the patient needed a painkiller or pain relief or they wanted to come into the hospital. They could access the unit and they still do the care and they were able to charge the government some amount of a few hundred dollars for their care. But how did that? I mean, it's just mind blowing. It'd be like saying, oh, you're going for your heart transplant, you had all your pre-care and your post-care for your heart transplant, but the surgeon's not going to get reimbursed at all for this. You know this really important level of care that you're offering and that's a philosophical question to you. How is it valued in the sense of a midwife on the floor? How is it that she is generating value to the health system? Or in the home? How is she making you know we all have to live right?

Speaker 1: 32:31

The care factor, which is about that humanistic touch, is not measurable. And so when you're looking at all the hospitals now and everything, looking at return on investment, we know, for example, that a name continuity of carer is cheaper for the health care system. We know that people are in for less time. But when you can't put a value on the humanistic element of it because it is so different, so if you can't put a value on it, it's devalued and it's not actually accounted for. It's too abstract, it's not concrete, you can't point your finger to it and go. That's an instinct, that's a caring. Let's put a money value on that and I think that's where our society in this capitalistic world has gone, and it's only the tasks that cost consumerable items that then become of value in the return on investment end of it. But we know that that and we know that it also is intergenerational, we know it's long term effects. Are we erode by accountants and politicians who only say in election cycles?

Speaker 2: 33:40

Well, I think that's a really good point. I mean, you think about, for example, the rise of C sections in the United States. You know, because you can charge it and it's a set time, it doesn't matter that later on in life women may have all these side effects from having multiple surgeries on our abdomen, but it's so convenient. Like, birth is inconvenient, right, you know, it's not convenient to be up at 3am constantly, it's not good for your health as a midwife or a human. But the acknowledgement that birth is not, you know, it's like we don't even know what causes labour. I mean, the young patients don't believe me. I'm like, look, I know we've been doing this for thousands of years. But if we knew? Like we don't even know. Like we know there's theories and there's chemicals and hormones and abdominal distension and approximately the baby will come at any time of any time in these approximate five weeks of time. And that's quite mind blowing for some of my clients that they're used to health care. They go to the doctor or the nurse practitioner or the provider and they get their prescription or they get their health scheme or they get whatever it is. They want this product. But this idea that I'm trying to sell you is well, we're doing all this care and surveillance and everything else. And here's you'll get your, hopefully get your wishes. And then you know, how do you I mean, how do you provision care that's safe and good if you can't be there? As you know, we have continuity of care, but we can't have a computer provider.

Speaker 2: 35:23

Because I did that, I tried that for three years, you know, in my private practice, and it was, I mean, was it good for the patients? Probably, you know, they knew the person and it was great, you know, and but it, you know, when you've been up for 30 hours and that's the thing we're going to talk a little bit of my doctoral journey, but I had to be on call for 24 hours to get the day off to go to the university, because I was required to be there live, but not being an effective learner as going back to school because I've been awake for many hours and talking about, you know, society doesn't value inconvenience. We're very oh, I want to meal. I'll just go and get a meal. I want, you know, I want to go on Amazon and get this thing because I need it Especially now this constant one.

Speaker 2: 36:15

Yeah, but this constant, like you know, like many of my patients, don't know how to cook. You know, I talked to them a lot about their diet, exercise and all this. And well, this young lady was asked to leave her home out of the blue when she was 15. So she had to leave home and became without a home and never learned how to cook. So that's like I mean, I can't run a cooking class, right?

Speaker 1: 36:44

I mean I could cook.

Speaker 2: 36:45

But that's a really important need for her going forward, that she's able to provide healthy, nutritious food for her child. But there's no like there's not really. Yeah, of course, but how do we again going back to the social determinants of health, how do we? How do we at least get? It's not even a level playing field. I'm not even going to go there. That's just so unrealistic.

Speaker 1: 37:13

The basics. I mean you're looking at Maslow's triad, you're looking at the very basics of food which are in safety.

Speaker 2: 37:21

Right, but if we can't meet the needs for food because they're living in a food desert, it's unsafe parts of where you know my patients come from. It's not safe to go outside, especially at night, you know, and there's no, there's no grocery store, they've got no money. So you know it might as well. When they say, oh well, this thing costs X dollars, but it was the same in Zimbabwe or wherever.

Speaker 1: 37:46

Yep.

Speaker 2: 37:47

If you have no ability to pay for something, it doesn't matter if it's. I can't remember what it was. It was something last week and it might as well have been a thousand dollars or five dollars. Yeah, it wasn't going to. It wasn't going to be taken up, it was the wrong. The wrong. You know action.

Speaker 2: 38:05

Probably all of you know on the podcast that America is based a lot on individualism, whereas where I came from it was a lot about. You know, my university has actually called for the common good, or the common wheel in Scottish, if you will. How do my actions impact you or you, or you or you? But this sense that maybe some of us are taken more than we should and others are missing out and they have no, they have no agency. They're not going to be able the 15 year olds and the teenagers or the older ladies, they're not going to have time to access care.

Speaker 2: 38:38

It's even like dental care here. Oh, yeah, you know things like that. How do we? How do we get this? You know community understanding that all of us should have a certain level of care, whether we take it up or not, because we have misgivings about the government or provision of care by an entity, but how do we have for most women and families, how do we get a reasonable standard of care so that we can achieve health for most of the population and have healthier outcomes? Because, as you know, florida and the United States are very poorly performing compared to most. Let's say Western style.

Speaker 2: 39:27

Style high and moderate resource countries. We're just doing and it's getting worse. It's not. We're not getting better.

Speaker 1: 39:35

The maternal mortality rate is increasing in a lot of the southern states, which is that's correct. But then you think of it as America, as a high resource country, which it is in certain areas. But there are states and areas within some states that would be deemed to be low income, low resource areas, which is where there's a lot of reasons political and government that go into it. But, yeah, their rates are increasing in an astronomical amount.

Speaker 2: 40:05

Going back to our last point about money, it's very money driven maternity care. So there's no providers and it's very rural. Here you think of Miami, and Florida is a very rural state. There's a lot of farming, if you go even 20 minutes down the road. There's farms and there's no providers. There's no providers from where we are to at least an hour and a half to two hours north and going south. There's not really a reasonable standard of care. And also to each coastline Patients especially and you know what it's like. You've got a patient that's had a baby before. They're more confident in their ability to birth, except it's typically going to be a little speedier. So these patients are very concerned because there's no, where there's nobody to call yeah, anything on the road.

Speaker 1: 41:00

Yeah.

Speaker 2: 41:02

And that happens frequently. And then of course they get so rushed in and it's stressful and all this and they'll probably get a bill as well, so they don't want to call 911 and then they don't want to go to this other certain facility or this facility they prefer. But if you, it depends and I don't know what it's like there, but what county you live in or where you call the 911 emergency services from they are duty bound to take you to the closest healthcare facility. Well now there's healthcare facilities north of us where we actually have an office. There's no ability to birth there. There's no obstetricians or midwives at that hospital anymore, because it's all about the Benjamins, it's all about the money again. So sorry to be a bit negative. That that's fine, but yeah.

Speaker 1: 41:52

Let's continue on, because we could definitely kind of continue talking. The healthcare system in America, I think, confuses most of us that aren't in America, and probably even those who are in America. So you're in New Zealand and now you're disappearing up to America. Did you do your masters in America or before you got there?

Speaker 2: 42:12

I've worked in New Zealand and when I got there I had my offer of my employment and I went to the board of midwifery and nursing and started work. So then when I came to these United States of America, as I like to call them, I landed free and the home was the brave. Unfortunately, there was no midwives at the hospital where I planned to work. So I had a job offer and in America we have wonderful nurses they're called Labour and Delivery Nurses, l&d, l&d nurse. So I signed on as a Labour room nurse. But that was another whole thing to do.

Speaker 2: 42:56

My immigration and all this and it was quite difficult and to work in a unit that never had care by midwives was very stunning. I was shocked. I was actually shocked at and you'd be shocked if you came and worked here the expectations of most women are so low. So it's amazing and the things I saw and I don't really want to get into it here about sexual violence and things that are visited upon women, because that's a lot. We could talk a lot and I do speak a lot about trauma and I know your reference already. We do know at least a third of our families are bringing unrecognised trauma and the amount of stories that I could tell you just in the last two weeks of my job, because I work as a full-time clinical midwife as well as an associate professor, but just the acknowledgement of the trauma that families have had before and it's completely unaddressed.

Speaker 2: 43:59

So yeah, so I came and they're like what's a midwife? Are you like a doula? And then having to call the doctor, call the doctor. And then I had and this might be funny to people that are not American so the first birth I was at the very nice he's a lovely man, we're the same age, we're very close friends and I still remember the room and everything. Well, they feel in this big cart, like a trolley cart, so all this stuff. I thought. I honestly thought they were doing a C-section in the room, oh my God. And then the call where's my stool? Where's my stool? And I went what? What do you need a stool for? Because I have to sit down. I've never actually seen somebody sit down to catch a baby. Oh, wow, and that was mind-blowing.

Speaker 2: 44:50

So just the disempowerment of women, the positions for birth, the lack of understanding, and I would like to claim a small amount of improvement. There's now many midwives at the hospital but it took. I was a nurse there for five years but during that time, indeed, I went back, because there's five different official titles for midwives in these lovely United States but I decided the one that was most in line with my understanding of birth is called a certified nurse midwife, which would require me to go back to university to obtain a master's degree, because my diploma, even though it's called, if you ask a American say it's a diploma, they think it's a degree but it's not considered a degree in Scotland. So I had to enroll at the University of Florida and I did my master's and that was interesting.

Speaker 1: 45:49

So was that coursework or research.

Speaker 2: 45:52

It was coursework. It was a lot in clinicals I had to do, it was 18 months and yeah, I was just shocked to the. I mean it was good in the sense. So for those of you who don't know, nurse midwives we also practice women's health, mostly as well.

Speaker 1: 46:08

So it's really nice.

Speaker 2: 46:09

You can see non-pregnant women and that can be a bit different from the age. I mean you see maybe 11 or 12 year-olds up to whatever people, even older than me, so you know and having prescriptive privileges and things like that. So the role is quite different and it was good in the sense, but I was quite frustrated because the way the birth was being well. I hate the term managed, please don't ever. I know active management is a great thing. Thank you, Irish people, but managing women is not actually a thing. We shouldn't be managing anything. We should be empowering and centering and listening and hearing as well. Hearing what your patient wants, not just listening, but trying to get to where they are. I love that expression of where they are. It's so hard. You know how hard it is Every day.

Speaker 2: 47:02

every day it's exhausting and you can't. You know when you're trying to teach this philosophy of care. I had to do my masters and then do my certification. I passed, they let me pass. So that was good. Yeah, yeah so, but it took me over a year. It's called privileges here. It's truly annoying clinical privileges. So to get permission from the hospital to catch a baby as someone that was not considered an obstetrician, that was very. It was a big. You know one of my young colleagues that we've just hired on. I'm very excited For her. She brings a lot of diversity to the table. But you know we're getting frustrated because it's just going to be a number of weeks, but having to wait a year, it was really humbling because, you know, but they must, they would want to see me, of course, because you know trying to say that midwifery is normal and it should be valued. But even now, you know, every week or every month here people are like oh, I thought they were, I thought they died out. I don't think that's a thing, midwifery or midwifery.

Speaker 1: 48:15

And that's where we're going to break it into part two, when Jane starts talking about her DMP and the rest of her career. Thank you for joining us today. You'll find all the links on Twitter, instagram and on the podcast website. If you are a midwife and you would like to share your research, your postgraduate studies or even the quality improvement projects you are doing now, then email me at throughthepinardcom, send me a tweet or send me a DM.