Leseliey Welch: Maternal health equity

October 27, 2022 0:57:58
Kaltura Video

Ford School Towsley Policymaker in Residence Abdul El-Sayed discusses reproductive and birth justice with Co-founder of Birth Detroit and Birth Center Equity, and former Deputy Director of the Detroit Health Department, Leseliey Welch. October, 2022.



0:00:25.0 Dr. Abdul El-Sayed: Good afternoon, everyone. I'm Dr. Abdul El-Sayed, I'm a Towsley Foundation Policymaker in Residence at the University of Michigan's Gerald R. Ford School of Public Policy. I'm also a physician, an epidemiologist, and formerly, I was the Executive Director of the Detroit Health Department where I got to work with our guest today. On behalf of the Ford School, I'd like to welcome you all for today's timely conversation on reproductive and birth justice. I'll be joined by co-founder of Birth Detroit, Leseliey Welch, and I'll give you just a brief snapshot of Leseliey's impressive resume.

0:00:55.3 DE: She is a Michigan graduate and current lecturer here at Michigan, Leseliey Welch is a public health leader with a business mind and a visionary heart and a tireless advocate for work that makes communities stronger, healthier and more free. Leseliey leads a team of birth workers, birth advocates and community leaders, planning Detroit's first freestanding community birth center, Birth Detroit, and is proud of the launch of birth center equity to grow and sustain birth centers led by Black, Indigenous and People of Color across the country. She has nearly two decades of leadership experience in city, state and national health organizations, and she served as Interim Executive Director of Birthing Project USA, Deputy Director of Public Health for the City of Detroit, where she and I got to work together and consulted in the development of Michigan's first comprehensive LGBTQ health center.

0:01:40.1 DE: This event is part of our Towsley Foundation Lecture Series, and I'd like to thank the Towsley Foundation on behalf of the Ford School for their support. As a reminder, there will be time at the end of the conversation for questions, and I encourage you to engage and ask questions in the YouTube chat box or tweet your questions to #policytalks. With that, please join me in welcoming Leseliey Welch. Leseliey, welcome.

0:02:00.5 Leseliey Welch: Thank you. Thank you Abdul for having me.

0:02:04.1 DE: No, it's a privilege and an honor to host you and just grateful to have the opportunity to talk about your incredible work. I wanna ask you, just stepping back, what brought you to this work? 

0:02:15.6 LW: So many things, I fell in love with birth before I was a mom, as a birth doula. There is just nothing like being at a baby's birth at... Parents birth in that way. And later I would have my own children, and one of them, Zoe was born premature and spent some time in NICU, but not low birth weight, and she is thriving and doing fine today. I've also experienced a late term loss myself. Been with my family, through the loss of my nephew born too small, too soon and dying the same day and have another baby born on their due date. And so I have personally experienced the grief and joy of pregnancy and birth, and my public health background, and then knowing that midwifery care makes such a difference in our outcomes for birth, and having the opportunity to work at multiple levels across the city and state. So my first job in public health in Detroit was as Healthy Start Project Coordinator, and my last job in public health in Detroit was with you as Deputy Director of Public Health. And as you know, there are so many initiatives to address maternal infant health, but none of them have focused on leveraging the power of midwives that are a critical part of the answer to the problems we face. And there are no birth centers in the city, and that should not be.

0:03:52.7 DE: Can you tell us a little bit about, as we zoom into a birth center as a solution to the challenge that we face, what is the state of inequities when it comes to Black maternal and infant mortality and health generally, and what are some of the causes behind that? 

0:04:10.1 LW: So there is a lot out there today in some ways, thankfully, bringing attention to the issue of disparities in Black maternal infant health, and so disparities around maternal mortality, around maternal morbidity and infant mortality, with Black, indigenous and communities of color having much higher rates. One important thing that I like to highlight around that is that our outcomes that we see today are a result not only of the structure of society that doesn't value all birthing people equally, but also inequitable care options. So we have these disparate outcomes, these inequitable care options, and within the care options we do have, studies show that a large number of birthing people experience discrimination and mistreatment, in fact, one in six. And folks are more likely to experience discrimination and mistreatment in prenatal care, perinatal care, if they are birthing in a hospital and if they are folks of color.

0:05:28.1 DE: I wanna dig deeper into that because on the one hand, we have medicalized birthing in such a profound way, which... Every life begins at a birth, and that should sound obvious to say, but this is perhaps the most natural physiological thing that we do.

0:05:47.6 LW: Absolutely.

0:05:49.2 DE: And at the same time, we've seen a dramatic reduction of infant and maternal mortality overall as we started to bring a scientific and evidence-driven approach to this, but that then led to medicalization. And one of the things that I really appreciate about your model is that it allows us to bring the same kind of evidence-driven insights to the experience of birthing that have saved millions of lives and at the same time, not medicalize it. And I'd love to hear how you think about the difference between evidence-based or science-based care versus medical care writ large, and how some of the institutions of medicine have sort of eaten this evidence and scientific-based approach and driven the kind of outcomes that we're seeing now, particularly among people who tend to be excluded from the experience of medical care in this country, disproportionately.

0:06:46.5 LW: I would start by saying, midwifery care is evidence-based care. That the model of care that views birth as a normal physiological life process is midwifery model care and is focused on centering birthing people and families. And when we dig into that, we see that the countries, or peer countries that do better in their maternal infant care have midwives as leaders in care and very integrated into their systems of care. And here, we do the exact opposite. I've said over and over that studies show between 80% and 87% of us could safely give birth with midwives in a community birth setting, we do the opposite and it's not on accident.

0:07:35.9 LW: And so when we look at the history of midwifery care in this country, or obstetric care in this country, we see that there is a concerted effort to move birth out of the hands of midwives, into the hands of White male obstetricians and into hospitals, and to do that in a very racialized way: Through policy and media and academic and literary articles about the midwife problem and how unclean Black midwives were. All of this, folks can read about and understand, that there is this historical shift, and so what we see today in the over-medicalization of birth is a result of that, and it's also the result of the ways in which we have tied into this system the economics and the business of birth.

0:08:31.5 LW: So the number one reason folks are accessing hospitals is childbirth. What does that mean in the grand scheme of things to suggest that hospitals should not be the primary sites of birth for everyone? And last thing I'll add to that is that what we also see to your point about medicalization is that the option of birth center birth is more likely to be available to folks who are White, cisgender, educated, upper-class, less likely to be available to folks who look like me, or who are Medicaid eligible, and so that means that we are automatically tracked into highly medicalized care that we do not necessarily need.

0:09:18.8 DE: I really appreciate you saying that and your points on this, and one of the pieces of history I want to draw out here is that the medicalization of childbirth, and the fight against reproductive justice, have their roots in the same moment in history, 1857, you go back to a physician named Horatio Storer, and he launched a campaign against abortion on behalf of the medical profession, because, implicitly, more and more birthing was being done by midwives. And there was a worry about whether or not doctors were going to continue to be able to monetize childbirth, and part of that... And the way that they weaponized this movement was by fear-mongering, among mainly White men, that the abortion movement was going to stop White women from having enough babies.

0:10:28.0 DE: And people don't appreciate this history, but you see in that same root, both the birth of an anti-abortion movement, that is speaking a medical or pseudo-medical language, pseudoscientific language, and fear-mongering about Black birth rates overtaking White birth rates, which the echos of this moment, you can hear that in the conversations that we're having right now. And the scary thing about that, the implicit part of that, is that the people that they were worried about around medicalizing our system were clearly White birthing people, specifically White women.

0:11:13.0 DE: And so you think about the institutions that get built out of that moment of history, and they tend to be medicalized birthing institutions, specifically catering to the population that they were fear-mongering about not having enough babies. [chuckle] And so from the jump, so much of the history writes out Black birthing people from that experience. I wanna ask you, as you think about this model, folks are really intrigued about what a birthing center, or a stand-alone birthing center does. Could you walk us through, you walk into it, what are you seeing? What are you feeling? Who's there? What are they doing? 

0:11:57.2 LW: So, a birth center is a freestanding home-like place where midwives are the leaders in care, providing prenatal care, birth care, postpartum care. And what we envision, I'll walk you through for Birth Detroit, is that we envision when you're walking into our birth center, you're walking into a place that feels like home. You're walking into a beautiful living room is your waiting room with books and materials for education around you, with birth art and birth education that reflects you and your culture, that you are greeted warmly, maybe even by name, by a team who knows you, who wants to know you and your family. At birth centers, you are not a number, and you are provided midwifery care in the birth center, and again, really focusing on normal physiological life process of pregnancy and birth.

0:13:02.5 LW: Really attuned to building relationship with the birthing person's family. We even involve the kids in prenatal visits at our current prenatal clinic. And then two, for our birth centers at Birth Detroit, we'll offer prenatal care, postpartum care, the option of a birth center birth, so when it's time to have your baby, you're not doing this mad rush to the hospital, you're calling your midwife, and you're showing up to this place that already feels safe to you, that feels like home to you, and you're having very personalized care.

0:13:38.3 LW: And you feel heard, you feel respected, you feel seen, and you're well cared for. Birth Centers also our midwives do postpartum visits, we do postpartum visits in-home for families. So one of the things that's true about our current in-dominant model of obstetric care is that you have the baby and people say, "Great, you had a healthy baby, you're fine." But we don't do that. Somebody is gonna come to your house, somebody's gonna check on you, somebody's gonna make sure you have the things that you need, somebody's gonna do that within 24-48 hours after your birth. Somebody's gonna do that in a couple of weeks. So it just is a very hands-on model of care, and a birth center, I would say to folks who haven't been inside one is like a maxi home, not a mini hospital.

0:14:30.9 DE: I really love that contrast. I know a lot of your past work, obviously, we got to work together for a couple of years in the city, and one of the programs that you led on while we were working together at the city was a program called Sister Friends. And I see a lot of parallels between Sister Friends and Birth Detroit, in the sense that so much of it is about building institutions that can support wrap-around community making for a lot of folks who don't have that in the context of their birthing experience. Can you talk to us a little bit about the role that community shapes and then the impact of our policy choices, the programs that we build in helping to scaffold community, and how that's taken different shapes in your work.

0:15:24.2 LW: Yes. Community is everything for growing healthy families, period. And what we lost with the undermining of Black midwifery is this very strong network of community-centered care providers that not only provided birth care, but took care of families in so many other ways, and met family needs in so many other ways and connected families to each other in so many ways. And so community has been the central focus and is one of the unique things about our roots at Birth Detroit, is really starting by saying, "We know a birth center is a good idea. Detroiters, do you think a birth center as a good idea? Do you want a birth center?" We did that through early conversations and surveys, and a community launch and learn, and we were volunteer-led, for our co-founders and I, and hosts of volunteer leaders for years before we became a paid organization. And so one of the principles we stand on is that we can be leaders in our own care in context where we start to remove all these barriers. Removing the barriers like access to capital, removing the barriers in policy that undermine midwifery care, that we stand ready to rebuild our community health infrastructures in the ways that are part and parcel of our history.

0:17:02.4 LW: We know how to take care of each other, and we just need to be reminded of it.

0:17:09.2 DE: As you think about some of the ways that the culture and the conversation that we have about birthing has taken shape, how much time and effort do you spend almost offering a different narrative, pushing back against a lot of the implicit medicalization of the birthing experience in the community and what does that look like? How do you engage with that cultural piece of things, the conversations that we share, the embedded language that assumes a certain set of institutions and assumes away other set of institutions. What has that looked like for you, and what has the process of engaging that conversation been for you? 

0:17:58.0 LW: Yes, I think it has first been about reframing the idea of a Black maternal health crisis. I think that on one hand, there's this attention to an important issue, but the way that the issue is framed has problematized Black birthing bodies instead of really addressing or bringing a structure analysis to a system that is really not good to any birthing bodies, but just as disproportionately bad for Black birthing bodies, and so trying to help people understand that, that there's nothing inherently wrong with Black birthing bodies, that although our system has medicalized childbirth, childbirth is normal. And when we think about medicalized care that is centered around the worst thing that can happen, that is centered around risk, that is centered around control in many ways, we instead are offering a totally different picture of what's possible.

0:19:14.1 LW: That it's possible to have birth be safe, sacred, loving and celebratory, and to happen in community, and particularly as well around the narrative is because we have set the bar at survival, it breaks my heart, but so many Black birthing people were just happy to survive, but that is not the bar, that is not the bar. That is not the ceiling, it's not the floor, it's like under the basement. Because we deserve high quality, transformative, radically loving high quality care that affirms our power, and I think it could be... Not I think, I know that really changing the culture of birth in this country could be a game changer for power building in our communities.

0:20:15.3 DE: I wanna ask you, we're in a community where folks always wanna see the hard numbers. So I'd love to hear a bit about the differences in terms of outcomes that the Birth Detroit model can offer. A lot of folks, as you said, and I don't want to walk us back into the crisis-based framing, but I think... What I hope folks can understand is that it's when you demonstrate advantage relative to the baseline of what we already do, which by the way, claims that it works better which is why we continue to give so much money to it every single year. And make no mistake, a lot of this has to do with money.

0:21:05.9 LW: Absolutely.

0:21:07.1 DE: That there is an opportunity here to demonstrate that A, this approach is better, but then B, there is so much more that we can build around both our culture and our policy once we establish a reframe of this issue. So I'd love to just hear a bit more about some of the outcomes of the model and what you've learned in your work.

0:21:30.4 LW: Yes. So we thankfully have some amazing recent reports that have come out that summarize the model of care. So, National Partnership for Women & Families, along with a host of partners including Birth Center Equity posted or released a community birth settings report. And so in terms of outcomes, we know that birth center care results in lower rates of preterm birth, lower rates of low birth weight, higher rates of breastfeeding, higher rates of family engagement, higher client or family satisfaction, greater experiences of autonomy and respect. And when that care is culturally centered, it is protective for Black birthing people. We also know for those who are interested in economics of it, is that birth center care is value-based care. It is care that can be provided in a lower cost way.

0:22:48.5 LW: So birth center care, our Strong Start study that focus on Medicaid eligible families found that it saved $2000 per mother infant pair for normal birth, but then factor in the fact that birth center care results in lower rates, certainly a cesarean of NICU admissions and all the things. There's the opportunity, some studies say there's the opportunity to save billions of dollars throughout our healthcare system. And so I think if we were really willing to take a step back and look at what's possible when we fully integrate midwifery and birth centers into our health systems, there are advantages for all of us.

0:23:42.6 DE: I really appreciate that. And thank you for walking through that. I think a bit about some of the fights that have been fought over where birthing people receive their care, and I recognize that the medical industry is not gonna give this up so quickly.


0:24:03.1 DE: I wanted to ask, what is the state of the conversation? Are we seeing a willingness to be open and engage on this? Or are you seeing pushback from hospitals and hospital systems against this model? 

0:24:20.4 LW: I will say that here in Detroit, I have been just pleasantly surprised by the level of openness and acceptance and support for a Birth Detroit. Contextually, I will say, Abdul, I really do believe that the COVID-19 pandemic really did something for folks' understanding of why it's important to have a place where birth happens, [laughter] that sick people are not. And so it kinda opened this portal, I would say, for a new understanding of the importance of midwifery care and birth center care. And so we at Birth Detroit started by opening our first neighborhood based Easy Access Clinic two years ago in partnership with Brilliant Detroit. And so there, we provide prenatal care, postpartum care, childbirth education, but our families are birthing with hospital or home birth partners and community and our hospital partners have been excellent with working with Birth Detroit.

0:25:25.2 LW: I also think that there's an opportunity, especially for Detroit, because there are no freestanding birth centers in Detroit. We'll be the first in Detroit and the first Black-led in our state. There's an opportunity to show what this can look like when hospital partners, insurance partners and community partners come together to make it happen. And so we have strong relationships and are growing them with our local hospitals. We also are a part of some policy efforts that involve state Medicaid and local insurance payers. So we have been very intentional, I would say, as a strategy about relationship building in our work to build Birth Detroit.

0:26:14.4 DE: Now, I wanted to ask in terms of the nuts and bolts of funding, let's say a family and a birthing person decide that this is where I want to seek my care, how would they engage the institution? How does the institution receive payment for the services provided, for folks on Medicaid can the care be reimbursed that way? For folks who are privately insured, can they get the same care? How has that conversation gone? 

0:26:51.7 LW: So in states where midwifery and birth center care are well integrated, private insurance payers, Medicaid payers easily facilitate payment for birth center birth, just like they would any hospital birth. An example of that is Washington State. Michigan, however, ranks very low on midwifery integration. And in fact, we're like number 34. [laughter] And we're also one of nine states that doesn't currently license freestanding birth centers or acknowledge them in a formal way despite federal acknowledgement, and that birth centers are in the Affordable Care Act and all the things. So for folks here in Michigan, we are working with the Institute for Medicaid Innovation, with state Medicaid, with insurance payers to prepare for when we open the birth center next year that that won't be a barrier. Birth Detroit is committed to not turning families away for care. It's also one of the reasons why we are established as a non-profit. The majority of birth centers across the country are for-profit entities, and do not serve Medicaid-eligible families because the business model does not support it. And Medicaid is challenging or can be challenging. And so we are committed to make sure no one is turned away from Birth Detroit.

0:28:25.7 DE: I appreciate that. And there's a broader argument about Medicaid, generally. Medicaid is one of those programs that is an incredible lifeline for folks who don't otherwise have insurance, and yet, because of opposition from people about the idea as to whether or not we should actually be invested in healthcare for low income people, it has been consistently undermined and made worse. Whether that's bureaucratically worse, meaning harder to get on, stay on, get reimbursement for coverage, or fiscally worse in what it reimburses for care. And the fact that Medicaid reimbursements remain substantially lower than Medicare or private insurance, certainly is a real barrier to organizations like Birth Detroit that are explicitly focused on providing healthcare for folks who are likely to be Medicaid-eligible. And these are policy choices that are made left... We'll just say right and center on these issues to systematically keep it that way.

0:29:35.6 DE: And we don't really think about it in terms of the cost of that in lives served. But that is exactly what it is. It's that when you sustain a program at less than what it ought to be to address the challenges it's supposed to address, you create all kinds of fall on or knock on disadvantages in the communities that you say you're serving. And so Medicaid always has its cake and tries to eat it too. And we have a choice, right? Do we want a system? I'd argue we want one system that benefits everybody in the same way, because all bodies... If we're serious about equity, we have to treat all bodies equally. But even then, there's so much that we could do to make Medicaid as it stands better, that then benefit organizations like Birth Detroit. I wanted to ask you, what are some of the policy challenges facing you right now in terms of being able to build, sustain and run this organization to serve the community that you're serving? 

0:30:37.6 LW: For birth centers in particular, and us here in Michigan, we really are centering in on the work around reimbursement policy. So reimbursement policy is interesting because it can be decided at the legislative level, the state Medicaid office level, the insurance payer level, all the levels. Ideally, [chuckle] it is integrated at the legislative level so that everybody is held accountable to it. So working on reimbursement for birth centers and for mid midwifery care in community and for midwives to be able to practice to the extent of their licenses in this state and be reimbursed. And then working on birth center licensure. So having birth centers be officially licensed in our state is important to us for our long term sustainability at Birth Detroit.

0:31:40.1 LW: And so we're working on that. We are also really thinking about just increasing the number of midwives, particularly midwives of color in our state and what it looks like to really make Detroit a destination where people wanna have babies, where it's the best place to have babies if you're Black. And I think that's possible. And then finally I would be remiss if I didn't talk about the threats to our reproductive rights in this time and the significance of protecting our rights to bodily autonomy, our rights to choose when, where, how, and if we wish to have children and to parent those children in sustainable environments. And so voting this coming November and voting in favor of reproductive justice is critical. I would also say for our state, I'm very proud of the fact that the current proposal is like citizen-led. It's an example for other states of a ballot initiative that is community grown, that is significant and that aims to protect our reproductive rights. And that is critical for us right now.

0:33:01.9 DE: Can you talk to us a little bit about licensure? I mean, are there organizations that license birth centers and do we just not have them, are they not able to license in Michigan or are they not certified? How does this differ from the example that you gave us, which was, I think Washington State.

0:33:20.9 LW: Yeah. So there is a national body, the commission to accreditate birth centers. And so Birth Detroit will be accredited by that body, so we are pursuing that accreditation as we build, and in addition to that, most states have within their state health regulations an acknowledgement of birth centers and a requirement... Some of them even have a requirement that Medicaid health plans have at least one birth center in their provider mix. So there are multiple levels, I would say, to policy that supports birth centers, there's the national accreditation, which is possible but not all birth centers pursue it, I will say that. There's federal policy that acknowledges birth centers like the Affordable Care Act is, and then there's state level policy, which is what we are missing right now in Michigan and working toward, that would really acknowledge the role of birth centers and the midwives in maternal health in this state and codify our reimbursement in ways that support our sustainability.

0:34:36.4 DE: So stepping all the way back, let's say we were able to make use arena of Michigan, and you could wave a magic wand and you could recreate Michigan's birthing system. What would it look like versus what we have today? 

0:34:56.4 LW: Oh, my goodness. At a policy level, we would enact progressive birth equity legislation, just like what was enacted in Colorado some months ago. They have the most progressive birth equity legislation in the country, and it includes all of the interacting and interlocking factors that impact reproductive justice and the culture of birth would be that birth is normal, sacred and celebrated for everyone. Midwives would be the leaders in care, folks would know that you can safely give birth and be cared for by midwives, and if, if you should have a medical issue and need medical obstetric care, midwives are gonna notice that, and they're gonna connect you and get you where you need to be, and then you would go to the hospital providers and that they would be equal partners in a common goal to have not only healthy babies, but healthy birthing people and healthy families, and we would see a culture that truly cares for and honors families, and Birth Center Equity which is a national initiative that I work around to grow birth centers led by folks of color across the country, we talk about beloved economy, what would it be like to have birth be the center of a beloved economy? To have the network of relationships you refered to be part and parcel of the culture of care in this country, and I do think that birth centers are a critical part of birth infrastructure to make that possible.

0:37:02.8 LW: To make it possible for families, to make it possible for folks wanting to train as midwives, to bridge the gap between a hospital birth and home birth. There's a lot of healing to be done, a lot of education to be done at the provider level, at the healthcare leadership level, and at the community level.

0:37:26.3 DE: I love that vision. And one of the things I really appreciate about that is, if you think about it, the only... Very rarely do people who are going through something that is purely physiological, not pathological, not a disease, show up at a hospital to do that thing, very rarely is that the case, and usually hospitals are for people who are experiencing illness in the moment, and the only way that we relegate the experience of birthing to a hospital is if we implicitly argue that birthing is pathologic, despite the fact that everybody's birth began at birth. And so this is not a pathology, this is physiologic, this is something that is a normal part of human existence, it's a fundamental part of human existence and I think taking it out of the hospital setting is critical. I really appreciate you laying out that vision in that perspective. There are a lot of folks who would love to get involved in the project, how can they get involved in Birth Detroit, or if there are folks who wanna build a Birth Washtenaw or a Birth Ingham, what would that look like and how would they go about building toward that outcome? 

0:38:34.0 LW: Yes. So first, I would share with folks that for supporting Birth Detroit, we are in the middle of our... Or at the beginning of our capital campaign to actually build the birth center. We bought our land recently and celebrated on that land and are raising money to build the building. And so we've raised about a million dollars of our $4 million goal for the next couple of years. And so I would invite folks who have the capacity and desire to support us financially, Birth Detroit, you can look at our website, birthdetroit.com, and learn about our campaign.

0:39:14.6 LW: The second thing would be, we love volunteers at Birth Detroit, we have four volunteer work groups, one that does center around advocacy and some of the issues that we talked about today. Folks can learn about those work groups and opportunities on our website. And third, for folks who want to initiate work around a birth center in their community, please reach out. We are happy to support, and I say we as in Birth Detroit locally but also in particular for folks who are listening, midwives and birth leaders in Black, Indigenous and People of Color communities, Birth Center Equity was founded to support you. And so please, you can learn more about Birth Center Equity at birthcenterequity.org. And again, Birth Detroit is birthdetroit.com.

0:40:12.7 DE: If folks wanted to build a movement around this, what would the number one most important policy advocacy point be right now? Like the one that is most eminent and most winnable.

0:40:27.8 LW: So the most eminent and most winnable in our state right now, I would say, would be reproductive justice and voting around Proposal 3 specific to birth centers. Second, I would say birth center licensure. We need that, we need birth center licensure that codifies our reimbursement and ensures our sustainability, those two things.

0:40:48.1 DE: I want to move to questions from the audience and I know Katie's working backstage to get us some of those. So if you do have questions, I hope that you'll go ahead and drop them in the chat in YouTube and we'll get 'em here. I wanted to... Just sort of stepping back, Leseliey, I wanna ask you... We talked obviously today about birthing equity and birthing justice, and it's impossible to disentangle any aspect of inequity from any other. When we, as a society, decide that we're gonna build institutions that fundamentally discriminate against folks of color, that shows up across all kinds of different spaces in people's life stages. As you think about the way that birthing equity intercalates with health across a life course, what are the spaces that we need to also pay attention to? What are the high-yield places of focus that... As you think about the beginning of a young Black life, what are the next spaces that we need to be invested in to make sure that that hand off of life is as equitable as it can be? 

0:42:16.7 LW: It's like really acknowledging justice begins with birth but it doesn't end there. That when we look at addressing the culture of birth in our country and wrapping our arms around birthing people and families at the beginning, I would say we can't let go. We can't provide rich and beautiful and comprehensive midwifery care in birth and then release families after that to this abyss of non-coordinated care. Pediatric services should be just as holistic and loving, our primary care environment should be just as holistic and loving. I think our early childhood education environment should be just as holistic and loving, and I also think when we think about just our young people and the care and education they receive around their bodies and around reproductive healthcare, we can do so much better. I have an 8-year-old and a 16-year-old, as you know, and we can do so much better around how we do that. And I would emphasize as well, like our capacity to really hold the mental and emotional healing that needs to happen all over the country, not just when it comes to birth and pregnancy and parenting but what it means to live a life in this country that still is so invested in a hierarchy of human value.

0:44:00.3 DE: I really appreciate that. And you think about this moment, I think the pandemic in so many ways laid bare a lot of the implicit decisions that our society makes about human value every single day. There was a question from YouTube about the role that the COVID-19 pandemic had in the birthing experience generally. Are you noticing more need for postpartum care, more complicated moments of delivery for people and what impact do you think the pandemic has had on the birthing experience more generally? 

0:44:37.7 LW: I think that or I know, and studies are coming out now to support and show that the pandemic made birthing more stressful [chuckle] in a context in which it was already not gentle. And so the pandemic stripped away from families the support that family provides, the support that doulas can provide and it has resulted in compromised quality of care and impacted outcomes. I would say specifically for midwifery care, the pandemic increased the demand for midwifery care, the demand for community birth, birth center and home birth, and has increased visibility, I would say, of community birth for the better. And so I do think that with time, my hope and my prayer is that our efforts today will ensure that midwifery care is normal 10 and 20 years from now.

0:45:50.0 DE: There is a question from YouTube. The State of Michigan 2023 budget includes 1.2 million for expansion of healthy moms, healthy babies, maternal and infant health and support programs to provide professional doula care services for pregnant women, new mothers and their families and to address disparities. Can you talk about how this and greater availability of community health workers might impact maternal health equity? 

0:46:15.2 LW: So I love community health workers certainly and I love doulas because I was one. One of my cofounders, Elon Geffrard is an amazing doula. And I would say community health workers and doulas are important. And at the same time, I would say that we cannot add community health workers or add doulas and stir. That there is so much more to be done structurally to ensure the outcomes we say we care about. So we do need community health workers and doulas, yes. And we need to allocate some of those funds to strengthening our midwifery care in this state so that Michigan is not number 34. If we had midwifery care integration and community health workers and doulas, we would be on fire, and we need to acknowledge all the things.

0:47:23.7 DE: And another question is, how do we get holistic and loving without radical changes in public policy? 

0:47:30.7 LW: So, we get holistic and loving by not allowing current public policy to limit what we know is possible. When I think about the care we're providing at Birth Detroit, one of the things we started with was that the spirit of care matters, the spirit of leadership matters and what we do at the community level, what we build will influence and change public policy. And so I think that that's where we start. We can't allow what we see [chuckle] to foreclose what we know we need and what we know is possible. And so we have to work up to it, we have to build multilayer strategies. At Birth Detroit our strategies are midwife, advocate, develop and engage. We're doing all four things at the same time because that is what we have to do to create the future we wanna see.

0:48:35.4 DE: Yeah, I really appreciate that point and I appreciate the spirit of the question. I think sometimes, given the context in which we're having this conversation in a school of public policy, we assume public policy to be the be-all and end-all of particular outcomes. And don't get me wrong, policy is critically important, it's why we're all here and why we're having the conversation. And at the same time, we have to always think about, how do we leverage policy as it stands to promote the best outcomes that we want and then leverage the work that we're doing to change public policy? There is no working on public policy in a vacuum as if we just kinda have to wait for policy makers to change everything and then things are gonna change. You can have really great policy and bad outcomes, and you can have really much better outcomes despite bad policy.

0:49:22.0 DE: And the key thing is to work at the edge of what policy will allow us to do to create the best possible outcomes and then leverage that change and that momentum to change policy itself. And one of the things that we did at this city which I think was important at the time, was to change what we did within the confines of current policy to demonstrate how policy ought to change. And I think when you can create those facts on the ground within the current policy setting and demonstrate exactly how it is, the current state of public policy is holding you back, it creates the kind of momentum that movement can use to change public policy. So there is an interlocking relationship between these two things.

0:50:06.4 LW: Yeah. I would share too, Abdul, and particularly for this audience, I think you all would be particularly interested in how Colorado came to pass the most progressive birth equity legislation in this country. And so there's a video about that on our Birth Detroit YouTube channel and you can learn more about it by going straight to Elephant Circle's website. It is a great example of what we're talking about here, the intersection of community and public policy.

0:50:37.2 DE: We'll definitely make sure to link to that. There is a question about... A really important question. What are your thoughts on maternal health from the perspective of the US prison system? 

0:50:52.7 LW: How much time do we have? [chuckle] No.

0:50:56.0 DE: Cue the next hour.

0:50:57.0 LW: [chuckle] Cue the next hour. There is so much work to be done there, I wouldn't begin to try to speak to it in these few minutes. I also think, and would be remiss not to say, that there's a tremendous amount of work to be done to our US prison system, period, to create a system that is truly... That really does heal our communities and hold and take care of mothers in the system.

0:51:38.0 DE: If I can pick up where you left off there Leseliey, I can't imagine... Let me step back. I have seen, though my imagination could not have conjured, the fact that we allow lives to begin in prisons. And one of the biggest follies of our public policy when it comes to the criminal legal system is we are caught between a notion that we aspire to be "corrective in healing" when too much of our system is based entirely in the idea of punishment. And the place where... The fault line where that is demonstrated in its starkest, most brutal and frankly most disgusting way is when you implicitly punish a new human being for something that their parent ostensibly has done. Never mind all of the brokenness in the way we police, in the way we sentence and the fact that incarceration, this idea of keeping people in jail is the way we think about "correction" but really actually punishment.

0:52:52.9 DE: But it's actually emblematic of so much of the rest of our public policy. When you say that you wanna fund an education system on property taxes when you know that there are fundamental differences in the value of property as a function of redlining, what you are saying is you want to punish kids for their parents' poverty. That's what you're saying. And so there is a far broader question about how we engage with honor and empower the transition of a life that forces us to ask how we engage with life as it is even before someone is newly born into the world. But the fact that you have people birthing in prison is really an indictment around the entire approach that we think about "punishment or correction" or "correction" but was actually punishment, but also how we think about poverty and how we think about marginalization and how we think about all these issues. When it comes to...

0:53:54.3 LW: And how we dehumanize each other. How we dehumanize each other too. What does it... What would it look like to be the most gentle with others at their most vulnerable moments? Pregnancy and birth are vulnerable, critical times from a spiritual, emotional perspective, a public health perspective, we talk about them that way, scientifically. And then we allow this critical process to happen and for folks to be not well cared for in this critical and vulnerable time. And that's sad, it is a ding on our humanity.

0:54:39.1 DE: Right, right. There was a question about... There's a question here about reproductive justice and we talked a bit about this but... And the question is, have you perceived a shift in the centering of abortion rights over, say, birthing justice or do you think we're doing a good job of incorporating all of these modes of care into reproductive justice imperatives which is the intention of the Reproductive Justice Movement entirely? 

0:55:17.0 LW: I would say that there's still a tension, a tension between a focus on abortion and abortion rights as an issue and then the broader reproductive justice context. But I would also in the same breath say that there is so much amazing work being done right now to address that very tension and to bridge that very gap, and that the work of Black womanist and feminist activists who have been doing reproductive justice work for decades, is being increasingly recognized and brought to the table, that it is informing things like our Proposal 3 here in Michigan that Loretta Ross even just, I think, won a MacArthur award. So I think that culturally now we are in a time of shift and we just have to keep pushing for folks to understand that reproductive justice includes abortion and is broader than abortion.

0:56:22.7 DE: Yeah. I really appreciate that framing. And at center here is the question of who has the right both to control their own physiology but also what kind of structures do we build to empower those choices? And I think that's one of the spaces where these questions come together. And more broadly, I've appreciated throughout this conversation, Leseliey, your framing on holistic and loving. And we cannot assume that the broader theme, the broader goals are divorced when we sorta segregate these issues. Frankly, the question is, who do you value and how do we value them both in the structures that we build and the rights that we guarantee? On that note, I wanted to thank you, Leseliey, for joining us here today for a really instructive, holistic and loving conversation about how we truly do pursue equity in the birthing experience and frankly beyond, and sharing with us your incredible project to bring that to fruition in Detroit and the opportunity to seed that and to continue to demonstrate the power of that model for the broader country and beyond. Leseliey, thank you so much for taking the time.

0:57:50.0 LW: Thank you so much for having me and thank you to everyone who has participated today.