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On the Hawaiian island of Oahu, a pregnant woman in her third trimester received a disturbing call from a friend.
“She told me she tested positive for Covid,” the woman recalled. “She was sick, she was feeling symptoms.” The two women had spent time together just the day before.
Unfortunately, the friend passed Covid-19 along to her. “It was really scary. I was worried about my own health and the baby’s also, being pregnant and being that far along,” the woman said.
Unsure of what to do, she turned to the midwives of the Oahu-based organization Healthy Mothers Healthy Babies Coalition of Hawaii (HMHB).
The midwives provided her with a doppler, a blood pressure cuff, a thermometer, and a pulse oximeter, and taught her how to monitor herself and her baby as she quarantined. They also brought meals to the house for her and her boyfriend. “They never made me feel embarrassed and ashamed about having it,” she said. “If I hadn’t had them, I would have been all alone.”
When she went into labor at 38 weeks, a midwife went with her to the hospital and acted as her doula. When her baby girl had trouble latching, they were there to help and answer questions.
For the midwives of HMHB, it was par for the course. They’re used to adapting to provide whatever it is their clients need – whether it falls inside the scope of traditional midwifery or not. (They prefer to call the women they serve “clients” rather than “patients” – a way of emphasizing that pregnancy and birth are normal parts of life.)
A brand-new mother may need access to food support. A pregnant woman, not knowing any English (HMHB’s midwives speak five languages in total), may need birth education. A woman already in labor in a local hospital, overwhelmed by her experience, may need a doula.
Since January of 2021, Direct Relief has supported HMHB with more than $34,000 worth of medications, equipment, and supplies, including 4,200 units of PPE and a solar refrigerator designed to be used in the organization’s new mobile van.
Roots in the community
HMHB became a nonprofit in 1992. At first, midwifery wasn’t a part of it – instead, the organization focused on advocacy and on direct social services, including providing food, cribs, and other provisions. Health centers and other community organizations would refer pregnant women and new parents to the organization to help with everything from diapers to rent.
“Nothing that I say about safe sleep, lactation, mental health is going to sink into a mama if she has food insecurity or housing insecurity,” said Sunny Chen, HMHB’s executive director.
But over time, the need for health services became increasingly clear. “Our moms have so many access barriers to care,” Chen said.
Jacquelyn Ingram, a program director at HMHB, agreed. When it comes to Hawaii, “people might think of tourism, and the glamorous side,” she said, but many of their clients can’t keep up with the cost of living.
In addition, “the high social risk moms that we serve have even higher rates of depression and anxiety,” Chen said. “The dream was always to add a clinical arm,” in large part to address these serious concerns.
HMHB started by contracting with licensed clinical social workers to care for women experiencing postpartum depression, sexual trauma, and other mental health issues.
Then, in 2020, when Hawaii began requiring the licensure of midwives – an important change in which HMHB played an advocacy role – they began providing prenatal and postpartum care, along with lactation services, to families in the community.
The midwifery model
Chen and Ingram firmly believe in the power of the midwifery model. Midwives “are in the community and they’re in people’s homes…they just have this amazing, worldly outlook in maternal care,” Chen said.
Many of their clients aren’t familiar with midwifery – in part because, in the United States, midwifery services are often out of reach for low-income clients. (In many other health systems around the world, midwives play a more integrated role.)
In particular, bringing midwifery services to patients of racial and ethnic minorities, whose birth outcomes are statistically worse, is a high priority. “Our niche is really the high social risk moms,” Chen said, although people seeing a midwife should have a lower-risk pregnancy from a medical perspective.
A higher-risk pregnancy is better overseen in a traditional medical setting, Chen said: “Then our midwives just become their doulas…and work hand in hand with their providers.”
For Ingram, community-based midwifery is a natural fit. A certified professional midwife and lactation consultant, she trained and volunteered with the Indonesia-based midwifery group Bumi Sehat early in her career. It’s a style of care she described as “low cost, low tech, but high love.”
The midwifery model of care is centered around the belief that, as Ingram says, “birth and pregnancy are part of life. It’s not like something is wrong.” HMHB’s midwives help clients make informed decisions about their own pregnancy, birth, and postnatal care. A big component of that is “spending time…getting to know them, the family, their situation.”
Although the organization’s midwives don’t currently do home births, they do act as doulas for women in labor at local hospitals.
“Work to be done”
The newest tool in HBHM’s belt is a “beautiful mobile van, fully stocked with amazing supplies from Direct Relief.”
The mobile unit was originally a touring van that Chen purchased from a used car lot. She parked it in her driveway, and she and her husband outfitted it themselves – a gargantuan effort that Chen estimates took 300 hours of labor and “my daughter doing homework in the van at night” while they worked.
The van makes it possible for midwives to overcome transportation barriers for clients and provide prenatal care in a safe and private space. It’s proved beneficial for everything from social distancing – “you can’t social distance in a small apartment with 15 people,” Chen said – to helping midwives safely screen women for intimate partner violence and sexual trauma.
The press they received from the mobile clinic has contributed to a dramatic increase in requests for their services. More than ever before, pregnant women and new parents are reaching out to them directly, rather than receiving a referral through a health center or other community partners. From fielding approximately 1,000 calls over a six-month period, HMHB is now receiving 4,000 calls over the same period.
And community organizations still reach out regularly. A maternal case worker may contact HMHB if a new mother needs a crib or is at risk of missing postpartum appointments. “As long as she’s not a high-risk mama…we can go fill that void,” Chen said. “Oftentimes it accompanies some sort of social services.”
Even as they provide maternal and antenatal health care, HMHB also offers culturally aware doula training and emergency skills training to other birth professionals. They help pregnant and parenting teens access food stamps and other benefits. And they perform a range of ongoing advocacy work, including a recent effort to encourage the state of Hawaii to expand the data it collects on maternal morbidity and mortality.
“There’s a lot of work to be done here, and we have to tackle it at all angles,” Chen said.