Dr. Rebecca Dekker – 00:00:00:
Hi, everyone. On today’s podcast, we’re going to talk with midwife, Dr. Jessica Brumley, about respectful maternity care. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi, everyone, and welcome to today’s episode of the Evidence Based Birth® Podcast. Today, we are excited to welcome Dr. Jessica Brumley, who is a certified nurse midwife with her PhD and a fellow of the American Academy of Nurse Midwives. Dr. Brumley has been a midwife for more than 20 years, and she is the current president of the American College of Nurse Midwives. Dr. Brumley is also director of the Division of Midwifery at the University of South Florida. She has helped grow a full-scope midwifery service that is an integral part of clinical care, education, and research within the College of Medicine Department of OBGYN at University of South Florida. Jessica has worked regionally to improve hospital transfers from community-based birth. She has partnered with the Florida Perinatal Quality Collaborative on statewide quality improvement work, including the promoting intended vaginal delivery and mother-focused care initiatives. Dr. Brumley’s research has focused on group prenatal care and human milk and lactation optimization. And everything she does, Dr. Jessica Brumley is out there striving to strengthen, grow, and diversify the midwifery profession. And Dr. Brumley, we’re so honored to have you. Welcome to the Evidence Based Birth® Podcast.
Dr. Jessica Brumley – 00:01:58:
I’m so happy to be here. Thank you so much for having me.
Dr. Rebecca Dekker – 00:02:02:
I was wondering if you could take us back to the beginning and share a little bit of your own personal journey. And like, how did you decide to become a nurse midwife and pursue this career?
Dr. Jessica Brumley – 00:02:12:
So I was 16 years old trying to decide what my major in college should be. And my mother suggested that I would make a good nurse. I don’t know why, but she saw in me. I was 16 and thought all the things a 16-year-old does. And I thought, I don’t want to wear those uniforms to work every day. My mom would wear like a suit to work at that time. I thought, not sure. And then I met someone who was a pediatric nurse practitioner and she came to our class and her, you know, white lab coat and dress clothes and talked about what she did all day. And I thought, oh, that’s a path that I could see myself doing. And I liked working with kids. So that seemed to fit. And then I entered the university and I started taking classes in women’s studies. And I learned about midwifery. And I start with the path about what took me to nursing because not everyone goes to midwifery through nursing, but it was nursing that brought me to midwifery. And so I was already deciding to go to nursing school. And then I learned about what it is to be a midwife. Someone in our class was training to be a midwife and they talked about empowering women and being part of this amazing process that could be life altering. And it just resonated with what felt like were my values. And so in that moment, at 17 years old, having never met a midwife before, I decided I would go through nursing to midwifery and that just felt right. And I was right. It has always felt right. And so I went on to complete my nursing degree and then immediately entered midwifery school following completion of my bachelor’s in nursing.
Dr. Rebecca Dekker – 00:04:12:
I think it’s really impactful that you use the word resonated, that it resonated with you. And I think of that almost like in the musical sense in terms of it creating these waves within you of meaning and intention. What do you think was it about that field and your values that felt aligned?
Dr. Jessica Brumley – 00:04:37:
I was raised in a family of many strong women. And my mother would have conversations with me about, she worked initially in a hospital in a community setting in New York, and she had a position where they had to look for funding to provide equitable access for mental health services. That was a small part of her role, but I remember having that conversation with her and having these ideas about fairness and justice. And so I think it really had to do with both of those things, the way I was raised, the people who were around me, the ideas that had been instilled in me and what was important. And so that those seeds had been planted. And so when I heard about what it is to be a midwife, what is the midwifery model of care, then that I believe sort of resonated with those initial seeds that had already been planted in me in my younger years.
Dr. Rebecca Dekker – 00:05:35
And you said the midwifery model of care, and I know some of our listeners understand that and others might not really know what that means. What does that mean to you?
Dr. Jessica Brumley – 00:05:44:
Some of the hallmarks of midwifery I think about are really being present with the people that we’re caring for, having a solid, strong understanding of what is the normal physiology and how to support that, how to incorporate the science and the evidence that we learn with what is important to the people that we’re caring for, what are the values and the experiences of the people that we’re caring for, and really bringing that all together for that family and for that individual in each encounter. I think that’s really what midwives are out there providing in all of the ways that they provide care. Many people think of midwifery as the pregnancy and birth care traditionally, but there are many midwives that are out there providing sexual and reproductive health care in other settings. It might be contraceptive care. It might be menopausal care. But an underpinning of that is understanding what’s normal and how do we support that, and then how do we support the individual to make the choices that are right for them.
Dr. Rebecca Dekker – 00:06:54:
And it makes sense that the ancient word that we’re using, at least in English of midwife means with women. So you’re kind of walking alongside people in their journeys. And it’s very much a collaborative effort, not kind of authoritarian approach. And that brings me to my next question, which is respectful maternity care. I know you’re doing a lot of work on this in your own research, also as president of the American College of Nurse Midwives. Can you define for us what is respectful maternity care and why is it so important?
Dr. Jessica Brumley – 00:07:31:
Absolutely. There are many organizations and individuals that have published definitions of respectful maternity care. I like this one. Respectful maternity care is an approach to care that emphasizes the fundamental rights of women, newborns, and families, promoting equitable access to evidence-based care while recognizing unique needs and preferences. And I like that this definition includes the idea of promoting equitable access to evidence-based care. So it’s not just a idea about how I’m going to treat the individual, but really also, I believe, includes this idea of justice in creating a system that is respectful of all the people that we’re caring for. I think it’s also important to understand the sort of opposite end of the spectrum and understand what is disrespect and how that can look, you know. And so thinking about things like, non-consented care or overuse of interventions, intrusive behaviors. So I think understanding both sides of the spectrum are really important in providing care in this way. It’s everything. Why is it important, right? I mean, it’s the reason why people are traumatized by their experiences in healthcare at times. It’s because it’s the way they’re treated, not always necessarily what happens, but the way that they’re treated when it happens. And so when I think about people accessing care or wanting to access care, it has to do with the way that they’re treated. People being able to feel confident in the care that they’re being provided, the recommendations that they’re given. It has to come from a place of respect and trust. And so it’s really fundamental. It’s, I believe a foundational tenet of anyone working in the patient care area.
Dr. Rebecca Dekker – 00:09:26:
And I can imagine in your long career so far as a nurse midwife, you’ve probably seen both types of care delivered, respectful maternity care, disrespectful care, even the obstetric violence side. And I was wondering if you could share a little bit about, you know, why this mattered to you. Was there a moment in your career when you experienced moral injury? Like, what was it that made you feel so passionate about respectful maternity care?
Dr. Jessica Brumley – 00:09:56:
I believe it’s my training as a midwife, right? It’s the philosophy of the way that we provide care. Many midwives come into midwifery because of a desire to change the system. This is what I see. They’re advocates for change. I think often we can feel a bit of an outsider in the system because of the way that we approach care. And so I’ve spent the majority of my career trying to create change in the system in which I am. And I’ve chosen to practice in the hospital because that’s where most people are birthing. And so I really wanted to create a place where people could come to birth and receive the care that they should be receiving. And at first, that started out as one-on-one care with patients. And then as I grew as a leader, it became about developing policies and procedures and changing culture and at the institutional level. And then partnering with organizations where we can do this for the profession or statewide at many hospitals. So what I would see in working in the hospital was that I had to be physically present in order for my patients to get the kind of care that I knew that they deserved. Oh, you don’t want the cord immediately clamped. Don’t worry, I won’t do that. But if I wasn’t there, I couldn’t promise that that wasn’t going to happen.Â
That seems maybe to people who are working in the field, like this very small thing, right? Like the timing at which I clamp the cord. But it’s a really big deal. All of these small things are really big deals for the people that we’re caring for. And so seeing that, seeing what were the routines. And when something’s a routine, it’s just part of the culture. It’s just how we do things, right? And so seeing that most people don’t enter the field in order to provide disrespectful care. But as they enter the field, you become acculturated into what are the norms in the way that these things are being provided. And so throughout my career, I’ve worked to change policies so that I didn’t have to be physically present, that this becomes the cultural norm. And as we changed policies around things like timing of cord clamping and skin to skin care, right, like there are lots of policies around intermittent auscultation and policies on nutrition and labor. All the things that I knew were foundational for midwifery and the patients I were caring for, that was so critical. And I was able to change policies. But then at the root of it is really about how we have this conversation with people and how we treat them in that moment. And it’s almost like the power they’re allowed to have in their care. That’s where I believe this work in respectful maternity care has become so important. It’s that it’s not about each intervention. It’s about the approach to the way that we provide care. It’s the way we’re thinking about who has the power in this situation and how do we support that.
Dr. Rebecca Dekker – 00:13:08:
I think, yeah, it’s almost like there’s the two buckets of problems, all of the little things that are not evidence-based or not family-centered. And like you said, you can write a policy, you can do training, you can change that. But it’s the overall culture, the water everybody’s swimming in is how do we talk to people? How do we show compassion and respect instead of being dismissive or short or, you know, even going down the spectrum of saying things that are coercive or disrespectful or pressuring people? Because it’s really hard to write a policy to say, don’t pressure people into things they don’t want as a patient, right?
Dr. Jessica Brumley – 00:13:51:
Yeah. You know, you’ve got the patient bill of rights. Of course, I don’t, you know, coerce people into care. And then when you see and hear examples of it, you go, oh. Maybe I have done that.
Dr. Rebecca Dekker – 00:14:04:
Can you give us some examples? What are some examples of coercion that you’ve seen?
Dr. Jessica Brumley – 00:14:09:
Even the simplest thing, the way that you say things, when you say, I’m going to do an exam now. Right. That implies that that person must open their legs and accept you doing the exam. It doesn’t allow them. In that moment to say, no, thank you. Right. It doesn’t even help them to understand why you think that’s important or to be a part of that decision making. And so it may not be so flagrant as right, like open your legs. I’m checking your cervix now. But that small little shift to say, hey, this is what’s going on. Would it be OK? What do you think? Or, you know, would it be OK if I do an exam right now? How do you feel about that?
Dr. Rebecca Dekker – 00:14:53:
Or would you like one now or would you like to wait until later?
Dr. Jessica Brumley – 00:14:56:
Exactly. Right. And then even just asking permission in that moment, right? Like saying, are you ready now? May I begin, right? Like just asking permission for everything that we do. That’s a small shift. It can be, it might even be the same number of words, but it’s just the way that you use them. Yeah.
Dr. Rebecca Dekker – 00:15:15:
I think that’s got to be a really hard thing to change, though, because I remember, I mean, I can even look at my journals from when I was in nursing school that they taught me to say, I’m going to listen to your lungs now when I put my stethoscope on someone. And it was presented as a way to show yourself as confident as a student, like you’re not timidly approaching them and you’re saving time because if they turn you down, you’re not going to get that exam done. So, you know, how many of our medical professionals in this country do you think were trained to approach birth in that way?
Dr. Jessica Brumley – 00:15:54:
All of them of a certain generation.
Dr. Rebecca Dekker – 00:15:57:
Okay.
Dr. Jessica Brumley – 00:15:57:
For sure. I mean, I have seen the shift now. It’s really, so I actually work in a school of medicine and I love that part of my job that I have an opportunity to work with medical students and residents. And, and I see that shift happening in our medical students now. And this conversation isn’t a new conversation for them. They’re getting that content earlier on in medical school and, you know, in their first two years. And so that’s exciting to see that it’s much easier to have this conversation with them because some of the foundational work, you know, is being had. Also, they have access to information in lots of different ways than, you know, we did, you know, a long time ago. And so it’s definitely been a shift. It’s varied. Some of it, I believe, is regional. I can see that when I travel around the country or even my state, like certain parts of the state are more sort of patriarchal in their hospitals than others. And some of it is like the cultural norms of that place. When you go to New York, it’s a little different than when you go to Georgia than when you go to California.
Dr. Rebecca Dekker – 00:17:02:
And one thing we haven’t really touched on yet, you’ve mentioned equity and equitable access, but how does racism and other forms of prejudice impact the ability to, you know, for respectful care to be the norm or not in a hospital?
Dr. Jessica Brumley – 00:17:19:
Well, it’s not something that people talk about when they hire employees into the hospital, right? At least not routinely in any of the places where I’ve worked. And so it’s really hard for people to know if somebody has implicit bias or are discriminatory. But that is part of what we try and work on at the state level when talking to hospitals around giving space for patients to report when they have inequitable experiences or discriminatory experiences. How do you center the voice of the patients that you’re caring for so that you can make changes in your hospital or with your group? It’s huge and it’s unfortunate, but I live in the South and it’s a scary sometimes place, right? When you hear about divisiveness that’s in our country right now. And people are a lot more vocal about it. And if you don’t address that with the people that you’re caring for, then you’re not addressing something that they’re dealing with. And so when things like the George Floyd murder protests were going on, my patients would talk to me about the fear that they were experiencing where they were living. I don’t think that that’s part of most people’s training on how to have conversations with their patients about the experiences that they’re having in their communities. So that’s one part. One part is how do you care for people who are having experiences of discrimination in their life in general? But then how do you also address the way that the system or their interactions with the system can also cause trauma and harm to them because they feel like. Well, you assumed because I’m Black that I have Medicaid or that I’m not married or, you know, sort of those kinds of biases that are happening. And where is the right place for people to express that, that they had that experience? And will it be responded to in a way that validates their experience? I’m not sure that our systems are set up to really have those conversations right now.
Dr. Rebecca Dekker – 00:19:29:
Yeah, I’m going to link in the show notes to an interview we recently had talking about a resource actually published in The New York Times that specifically talks about how doctors can have these conversations. And I think it would apply to midwives as well with their clients about racism and the fears related to that. But you mentioned a couple of things that also struck me, just even thinking about employee management and how hospitals typically don’t have a way to screen out. Are they hiring people who are outwardly and explicitly racist? I think that’s an interesting point that you made. And they may be hiring on the unit people who are unsafe for people who are LGBTQ and giving birth. That’s something that just like thinking of a management, like coming from as a business owner, of course, I would never hire somebody who’s explicitly homophobic and all these things. And but this may be happening in a community hospital. And then the other thing you mentioned is kind of your work at the state level. And that’s where I wanted to pick your brain, because I know you’re doing work at the patient level in a university at the state nationally with ACNM. And I love seeing all that, although I’m going to have to pick your brain later about how you do all of this. But your work with the Florida Perinatal Quality Collaborative has been focusing on a couple different projects. Can you share what those projects are and how they kind of fit in with respectful maternity care?
Dr. Jessica Brumley – 00:21:00:
Absolutely. The Florida Perinatal Quality Collaborative is a really strong collaborative. Most states, I believe, have perinatal quality collaboratives. Ours has been continuously funded through a variety of mechanisms and is housed within the University of South Florida College of Public Health. And so that has allowed me to remain really closely involved in the work that they do since I’m also employed at the university. And so that’s been a really natural fit for people in my department and including myself. And I’ve represented the state organization of nurse midwives that are ACNM affiliate at the state to this collaborative. And it’s really a collaborative of partnering organizations and there are a few employees that are employed by the College of Public Health.
Dr. Rebecca Dekker – 00:21:47:
Does it include public health experts, midwives, nurses, and physicians?
Dr. Jessica Brumley – 00:21:52:
Doulas, patient advocates, payers, really every stakeholder that we could think to bring to the table is either on the steering committee and or on the individual project groups. And so it’s really a broad cross-section of stakeholders in the state. And so I represent the state and the steering committee, and we try and have a midwife as a representative on each of their projects. And so the first project that I worked on was basically it’s a reducing Cesarean project or promoting intended vaginal deliveries or the PROVIDE Initiative. And that just resonated with me, right? I’m a midwife. Everything about what I do is about promoting normal physiologic birth and optimizing outcomes in that way. And so I wanted to give of my time to do that work. Through the course of that work, they received some additional funding in order to provide labor support workshops throughout the state as a way to support the hospitals that were doing this work. And so myself and a doula and public health professional that they had on staff worked together to create a curriculum to provide to any of the hospital team members that wanted to come to a workshop. And California had brought together a similar curriculum and they graciously shared it with us and then we modified it. And so we created an all day class that explained both the initiative, what we were trying to do at the state level to reduce Cesarean section.Â
What are some of the drivers of Cesarean section? So we talked about the initiative and then we reviewed the evidence on coping and labor, pain management and movement and labor and different positions. And so we had both lecture and hands-on practice and we’d bring in a hospital bed and birth balls and peanut balls and all the things in the classroom to practice. And we’d have case studies that we talk through and problem solve. Like, how would you navigate this conversation with someone who wasn’t open to having a person on their hands and knees while they were pushing or those kinds of things to help the people learn in the workshop how to facilitate this happening in their hospital? And so the funding that we received allowed us to travel around the state and present these workshops. It was mostly nurses. We had a few midwives and physicians and doulas that attended the workshops as well. So that felt like a natural fit for me. I mean, it was just like, you know, everything that I’m passionate about. And I’ve been able to present that work to other states and even presented that work in Vancouver. I was invited to the midwifery program out there. So that was really exciting. And then I built relationships during that. And they would ask for feedback on what they thought, you know, sort of their next initiatives should be. And I really felt very passionately about birth equity and how that was work that we really needed to be doing in our state. And so they asked me to be one of the co-leads for their next initiative, which ended up being titled the Mother-Focused Care Initiative.
Dr. Rebecca Dekker – 00:25:12:
What is that initiative about then?
Dr. Jessica Brumley – 00:25:13:
So that initiative is about addressing social determinants of health. It’s about providing respectful maternity care. It’s about centering the voice of the people that we’re caring for by having a mechanism to allow them to share their experiences and also including the patient voice on your initiatives. And so the thought process is that all of the other initiatives are really about improving a certain metric, improving the way that we address a certain concern. So reducing Cesarean section, preventing or optimally treating postpartum hemorrhage, hypertensive emergencies. These are very clinically practice bundles that we implement. But this one is really about providing the infrastructure and support and resources that people will need in order to implement the other bundles in a way that is very patient centered. You can’t address inequitable care and disrespect in the hospital with just one little bundle. We understand that it’s going to be foundational to all the work that people are doing. But really wanted to have one initiative where we gave people foundational tools and processes and saying, these are some things that you can start implementing so that when you do work on the hypertension initiative, you can say, but are we meeting the needs of all the people that we care for in this way? Is this equitable? All right. Are Black women having different experiences than white women, than Native women or Indigenous women? So trying to give people those tools in one initiative to be able to start to implement it moving forward in other initiatives.
Dr. Rebecca Dekker – 00:27:00:
It sounded like when you were describing the first workshops where you’re kind of traveling around the state training hospital staff and you said it’s mostly nurses. It sounds like the nurses are getting on board with these kinds of initiatives. The midwives are already on board. And of course, the doulas. What about physicians? What’s their involvement been? Do you feel any pushback or what’s a better way to reach that group? Because given that they have so much power over what happens on a hospital labor and delivery unit.
Dr. Jessica Brumley – 00:27:30:
It’s really interesting. Across the spectrum on all the initiatives that we participate in or engage with hospitals, getting physician involvement can be a challenge at the hospital level. We always have quite a bit of physician support at the FPQC or the state level. So my co-lead for the mother focused care initiative was a physician. Every hospital has to have a physician champion that is on their team that is working with them to implement it. But getting physicians to show up to trainings, right? Like I couldn’t get a physician to show up to an all-day training. The nurses will be, you know, would be compensated for attending an all-day training. That would be, you know, in addition and above to what is expected of our physician colleagues. And so we really have to think about ways to meet them where they are, to get them the information when they’re on the unit, when they’re in their staff meetings. When they’re having their staff lunches in their offices. So we really get creative on how we got to them, how we get the message to them. And is there sometimes pushback? Sometimes. I mean, there’s pushback from all people. But yeah, absolutely. Sometimes when you say things like we’re here to talk about respectful maternity care, most people say, what do you mean by that? I provide respectful care. Everything I do is respectful. So we definitely..
Dr. Rebecca Dekker – 00:28:55:
Are you saying I’m disrespectful?
Dr. Jessica Brumley – 00:28:57:
Exactly. Exactly, right? So we had to really get creative about how we have those conversations in the mother focused care initiative. One of the components of it is providing respectful maternity care education. And so I went around the state again and I provided these workshops to trainers at every hospital that was participating in this project and went through the International Confederation of Midwives Respect workshop. They have created a workshop that is free for anyone to use. And so we really like how they set it up. And so we modified it and use that workshop. And one of the opening activities in the workshop is asking people to stand up. And then you ask them to sit down if they have never experienced disrespect in the workplace before. And no one sits down because everyone, this is like a universal experience, but it’s a really powerful little moment in that you can look around and see that everyone is experiencing disrespect in the workplace. And then they sit down and we talk about types of disrespect or categories. And I ask them to write an example and a little sticky, and then they put it up on the board and they give examples of disrespect that they have seen. And everyone has an example. And it’s really powerful to read off these examples in that room. They’re the same.
Dr. Rebecca Dekker – 00:30:22:
Is it disrespect from co-workers or patients? Like what kind of disrespect?
Dr. Jessica Brumley – 00:30:27:
All of it. So that’s what’s really interesting is that they will give examples of disrespect from co-workers. It might be a physician complaining of disrespect from an administrator. But I would say the vast majority are examples of disrespect that they’re seeing towards patients.
Dr. Rebecca Dekker – 00:30:45:
Oh, towards patients, not from patients.
Dr. Jessica Brumley – 00:30:48:
Right. Yeah.
Dr. Rebecca Dekker – 00:30:48:
Oh, okay. I was thinking, you know, there’s so much attention on like unhealthy workplaces for healthcare workers and how they, you know, I’m thinking my friends who work in the emergency room and they’re cussed out and yelled at.
Dr. Jessica Brumley – 00:31:02:
We get those examples too, right? So it’s really, it’s really interesting and how it’s all intertwined. So then we have this conversation, right, about how, well, number one, if you’re being treated in a disrespectful way, particularly by your colleagues or other people that you work with, how can you be expected to provide respectful care? If your voice isn’t being heard by your administrators and supported, then it would be understanding, right?
Dr. Rebecca Dekker – 00:31:26:
It creates a culture and everybody’s swimming in the same water of disrespect.
Dr. Jessica Brumley – 00:31:31:
Exactly. Exactly. And then they give these examples of things that they have witnessed. I would say the vast majority are either non-consented care like cervical exams without consent. Coercive behavior are probably the vast majority. And then also people witnessing biased comments about certain patient subgroups. Probably the one that we heard the most is people with opioid use disorder. We have a huge problem with that in our country, but in our state, it’s particularly difficult. And so those were some of the most common examples that were given. And so as we had these conversations, it opens up people’s eyes to what’s happening, but also what other people are perceiving as disrespectful may not be what they had perceived as disrespectful.
Dr. Rebecca Dekker – 00:32:20:
Like, oh, if I’m talking, you know, making fun of a patient’s weight or I’m using demeaning language about them and their opioid use. I didn’t realize that was disrespectful.
Dr. Jessica Brumley – 00:32:33:
Yeah.
Dr. Rebecca Dekker – 00:32:33:
And other people are overhearing it and hurt by it as well.
Dr. Jessica Brumley – 00:32:37:
Exactly. Yeah. Yeah. So starting the conversation like that, I think really shifts how the rest of the day goes and how open people are to the content that’s received. Because it really sort of sets the stage for this is what’s happening in our workplaces. How do we change that?
Dr. Rebecca Dekker – 00:32:56:
I am so glad that you mentioned the resource from the International Confederation of Midwives. So we’ll link to that in the show notes, internationalmidwives.org. They have a whole respect toolkit, which you educated me on this. I did not know this was a resource out there. Like you mentioned, facilitator guides, presentations on how to run a workshop. And this is all free to the public, correct?
Dr. Jessica Brumley – 00:33:18:
Yep. It was the basis of the workshop that we taught. And so the first two hours, I used that facilitator guide and I created a PowerPoint slide set around it. And so we talked about things like adult learning theory and sort of why the workshop is taught the way that it is taught to help to encourage and facilitate action and change and all of the tools that they would need to potentially modify the workshop. And so if you’re going to teach it in an hour or if you’re going to teach it in four days, what do you keep and what do you cut out? You know, what’s really important? These conversations, these activities, that dialogue, that’s really critical, particularly when you’re working with adults and sort of how we’re going to facilitate people to engage in the content. And so..
Dr. Rebecca Dekker – 00:34:01:
You can’t just feed them the info they have.
Dr. Jessica Brumley – 00:34:03:
It can’t just be me talking for an hour over some slides. You know, that’s just not going to be effective.
Dr. Rebecca Dekker – 00:34:10:
What are some of the effects you see, you know, maybe that aren’t super measurable, but at the conversations at the end of the day, you know, what, what are people determined to do differently as a result of going through this curriculum with you?
Dr. Jessica Brumley – 00:34:24:
So that’s really exciting because that’s one of the questions that we ask them. What are you going to commit to doing in the next 30 days, 60 days, 90 days, and sort of start to create their 30, 60, 90 day plans. And they’re committing to do things like, speaking up when they see examples of disrespect, right? Giving people feedback when they’re witnessing it on the unit. We talk about power of feedback as a tool to help create a culture change. People will treat you the way that you let them treat you if you don’t say something about it. We talk about a zero tolerance for disrespect policy in the workplace and how administrators can help to support their team by implementing that. They obviously, and what we hoped was that they would commit to teaching these workshops or some version of them on their units to attend meetings. The physicians are, the providers are, and start having these conversations. People have gotten really creative about ways that they will start to share the message and sort of meet people where they are. So that’s been exciting to get that feedback on how they have implemented it.
Dr. Rebecca Dekker – 00:35:31:
Kind of rabbit hole I’d love to pick your brain about is respectful care during a transfer from a home birth or freestanding birth center birth to a hospital birth when it’s either medically necessary to transfer care or the patient has chosen to transfer care for pain management reasons or exhaustion. What are some of your goals and how you’re like working on that key point? From my understanding is that is often when you can see disrespectful care, some bias against those patients and being received respectfully. And then having that respectful communication handoff between providers can actually make the birth safer, improve outcomes. So what thoughts do you have on that whole process and how it’s going in Florida right now?
Dr. Jessica Brumley – 00:36:18:
I think in Florida, it’s really varied depending on the area where you are. And so I can speak to the work that we’ve done in our area to optimize that. And I started from a place of, this is the right thing to do, right? People are coming in and they’re having bad experiences in the hospital because of how they’re being treated. And that worsens complications in future pregnancies as well. They’re not going to want to come back to us, right?
Dr. Rebecca Dekker – 00:36:47:
Right. So they delay coming in until things are worse.
Dr. Jessica Brumley – 00:36:51:
So that was sort of my argument. That was what I was able to say foundationally. We have to do better because we want better for birth in our community. People have the right to choose where they’re going to birth. And we need to make this as safe of a process as possible. And starting from that common goal of we want birth to be safe and respectable in our community, and we can be part of that solution. In midwifery, licensure and regulation is varied by state. So in Florida, we have two midwifery credentials. We have certified nurse midwives, mostly working in hospitals, but some are working in homes and birth centers. And then we have licensed midwives. They don’t have to necessarily have the CPM or certified professional midwife credential, but the regulation in Florida of what it takes to become a licensed midwife is basically equivalent to that. The midwives that are working mostly in community-based birth. And I recognize that there can sometimes be bias around different midwife credentials. And it was important to me to explain to people and educate the people in our healthcare system around the different midwife credentials, their education, their training, their scope of practice, right? These aren’t individuals that are out there practicing without a license that are untrained that don’t know what they’re doing. They’re licensed.
Dr. Rebecca Dekker – 00:38:15:
And they’re specialists in community birth.
Dr. Jessica Brumley – 00:38:17:
Exactly right. And so that was really important to me to do that education. And then also to reach out to them because it’s really a lot harder to, I don’t know, talk bad about people when you have broken bread with them and met them and understand that these are people who are educated and trained and really passionate about the work that they’re doing and the people they’re caring for. So we literally just started by meeting at like a local like sandwich shop and just invited, you know, whatever midwives, you know, wanted to come to sit and talk and talk about like, how can we improve transfers to the hospital?
Dr. Rebecca Dekker – 00:38:57:
And so who was at this meeting from the hospital side or these not meetings, but meetings?
Dr. Jessica Brumley – 00:39:01:
So, I mean, it just started with myself and another one of the midwives on my team. And then we just invited whatever community based midwives that were out there. And we just started having these conversations. It’s grown where now these kinds of meetings happen in the hospital and we’ll invite physicians and nurses and really try and get an interdisciplinary approach to addressing how to improve the processes that we have. But it started with literally just like, let’s have some coffee and let’s talk. And building those relationships helped those of us that attend meetings have conversations with other people and say, oh, no, but, you know, that’s Jane and she’s great. And, you know, I have great transfers from her all the time. So it helped to have them hear us talk about these other professionals in a very respectful way and to start building those bridges. And then we created some guidelines around communication when a transfer needed to happen. And so they could call the midwife directly on our midwife cell phone. We always have someone in the hospital. And so we felt like it would be easier if it was a midwife to midwife transfer and that that would help the patients feel more comfortable with who was going to receive them in the hospital. But also the midwife, you know, feel more comfortable communicating with the person who was receiving their call. And then that grew because they would call us not just when somebody needed to transfer, but sometimes just when they needed a question about how to access our system, because the patient needed a certain kind of referral or ultrasound or non-stress test or something that the patient needed. And then we could help answer their questions around how to get patients the care they needed. So instead of saying. You’ve got to go to the hospital now. The midwife could now say, oh, it’s going to be so great. You’re going to go see Jessica. She’s fabulous. I know her. They’re going to take such good care of you, right? Like, we know that stress impacts the physiology of labor and birth. How do we make that less stressful? It’s stressful enough as it is. We need to be welcoming, respectful. So that’s the work that we’ve been doing and continue to do. It’s not quite as structured as I think it could be. There’s some work that has been going on in Washington State, the Smooth Transitions Program, and they’ve created a whole toolkit on how to optimize transfer from community-based to hospital maternity care. And they have a lot of recommendations, even including pediatricians when there’s a conversation around the baby. I would love to do that work to take it to the next step. I’ll be honest, that probably has to wait till after I’m done with my presidency.
Dr. Rebecca Dekker – 00:41:48:
I was going to say, don’t take on any more projects.
Dr. Jessica Brumley – 00:41:51:
No, it’s like gold, you know? And then also like-
Dr. Rebecca Dekker – 00:41:53:
Crush your gold.
Dr. Jessica Brumley – 00:41:54:
Yeah, exactly. Yeah. But it’s important work. It’s important work. And so I also hope to inspire other people to want to do that work instead of-. Yeah.
Dr. Rebecca Dekker – 00:42:05:
Well, and I’m sure, you know, this is generational work, so we don’t have to all complete it. But also, we’re not alone, like you were just saying. And one step at a time, too.
Dr. Jessica Brumley – 00:42:17:
Absolutely. Exactly.
Dr. Rebecca Dekker – 00:42:19:
When you’re done with the presidency, maybe that will free. More room on your plate to take on something else that you want to do. But that brings me back to, you know, being a leader in midwifery. I feel like you’ve done such an amazing job today of explaining why respectful care is both safer and it’s just the right thing to do, you know, and how midwives should be consulted as leaders in this movement. I hope this movement is I mean, I hope it spreads, but I don’t want it to be co-opted. I hope midwives and doulas continue to be seen as leaders in this, through your presidency at the American College of Nurse-Midwifery and your other leadership work, is there anything else you want to share right now? I’ll just give you an open floor to talk about anything else you want to mention while we still have you here on the podcast today.
Dr. Jessica Brumley – 00:43:11:
I feel that embracing midwifery in this country is a huge missed opportunity that we’ve had. And I know that we need to really incorporate midwives into our health care system at a much higher level. All the data supports it. It helps to improve outcomes. It helps to improve experiences internationally. And also we have evidence that shows that midwives more integrated into their states have better outcomes. And so the evidence is really strong. We really need to champion the work of growing and integrating midwifery into the workforce at a much higher level. It’s critical to the care of the people in our communities. I love this idea of a birth center for every community, a midwife for every community. That’s our mission as the American College of Nurse Midwives or our vision, right? A midwife for every community. That’s what we’re focusing on as an organization. How do we improve the environment for midwives so that can fully practice to the full extent of their education and training. How do we create legislation and regulation so that midwives are respected and welcomed in the healthcare system, reimbursed at an equitable rate? That’s really what I think is going to make a difference in us being able to keep midwives in practice and then attract more people to the practice of midwifery.
Dr. Rebecca Dekker – 00:44:48:
Right. Growing the profession involves training more students. But also making sure that they feel like you said, they can practice in a safe, respectful environment. And we’re not, yeah, just throwing them on the floor, like eggs on the floor. Like, oh, we don’t have enough midwives because we keep throwing the eggs on the floor.
Dr. Jessica Brumley – 00:45:08:
Exactly. Exactly. We did a workforce study recently. And what we found is that 30% of midwives leave clinical practice in about five years now.
Dr. Rebecca Dekker – 00:45:18:
Wow. That’s a lot of school to only practice clinically for five years.
Dr. Jessica Brumley – 00:45:25:
Yeah, exactly. Right. I said I wasn’t even like great at five years. I mean, I was good, but. You know, so it’s this lost opportunity. So we have to stop the funnel. We have to stop the loss. And when we do that, then it will also create a space where more people will want to come to the profession. For sure. Yeah.
Dr. Rebecca Dekker – 00:45:48:
Well, Jessica, thank you so much for coming on the podcast today, sharing your wisdom and your experiences with us. We’re just so grateful for the work that you do. And I feel like I learned so much from you today. I hope our listeners did as well.
Dr. Jessica Brumley – 00:46:00:
Thank you so much for having me. You’re a gracious host.
Dr. Rebecca Dekker – 00:46:05:
And where can we follow your work?
Dr. Jessica Brumley – 00:46:07:
Oh, sure. I mean, I’m on all the social media platforms. Brumley CNM is where you can find me.
Dr. Rebecca Dekker – 00:46:16:
Awesome. And we’ll link to the Florida Perinatal Collaborative and your USF profile so people can go to learn more about you and the work you’re doing. And thanks again, Jessica, for joining us today.
Dr. Jessica Brumley – 00:46:27:
Thank you.
Dr. Rebecca Dekker – 00:46:28:
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