Current Policy Initiatives
A multi-faceted approach is needed to achieve birth justice in New York. Most urgently, as the COVID-19 pandemic has shown, out-of-hospital birthing facilities and community-based prenatal, birthing, and postpartum care are not only beneficial public health measures, but necessary in times of social crisis.
Remove barriers to midwifery-led birth centers
In the last twenty years all but two of the birth centers in NYS have closed owing to high malpractice insurance rates and operational costs (rooted in high rents and low insurance reimbursements), or have been eliminated by large hospital conglomerates in favor of more lucrative offerings such as private postpartum rooms.
Even after landmark NYS legislation in 2016 legalizing midwife-led birth centers, and advocacy from the NYS Covid Maternity Task Force’s recommendations, NYS midwives have not been able to open birth centers due to restrictive NYS Department of Health regulations and licensure processes.
Recommendations for NYS:
These regulations and the licensure process must be amended so as to follow national accreditation guidelines rather than the current burdensome NYS Certificate of Need (CON) process that was meant to apply to large-scale hospital facilities, not smaller community centers. The CON is cost prohibitive – approaching 20% of a small birth center’s opening costs – and entails a two-year process before construction permits are even issued. The CON process is overseen by the Public Health and Health Planning Council (PHHPC) which is populated by representatives of large healthcare institutions and does not represent birth advocates. Other barriers to birth centers include a requirement for hospital transfer agreements which are difficult to obtain owing to hospital intransigence.
To further support birth centers, midwives at birth centers must be granted privileges at the closest hospital transfer location to allow some continuity of care in case of transfer. Hospitals must not unreasonably deny transfer agreements with the closest birth center; must collaborate with the birth center on best transfer protocols; and offer training on out-of-hospital birth for hospital staff who will be accepting transfers.
Creation of a state governmental malpractice insurance carrier to help keep malpractice insurance costs for midwifery-led birth centers low
Create a consumer advocacy department to offer midwives interested in opening birth centers guidance on navigating the NYS DOH regulatory protocols, negotiating fair reimbursement with insurance companies and Medicaid, and receiving access to grants and funding.
Support birth centers through publicly funding midwifery-led free-standing birth centers associated with all public hospitals in NYS that offer maternity services.
Recommendations for NYC:
Create publicly funded midwifery-led, free-standing birth centers
Bring back cost-saving birth centers at all NYC H+H public hospitals that offer maternity services.
Incentivize and support independent midwife groups like The Birthing Place, Bronx and Haven Midwifery Birthing Center, Brooklyn looking to open birth centers with access to space, funding and small business support.
Write resolutions in support of state policies to expand birth center access.
Read more about the need to remove barriers to midwifery-led birth centers.
Expand and diversify community midwifery care
Community-based midwifery care can improve maternal health outcomes and patients’ experiences while also reducing costs and benefiting those most at risk – particularly people of color and those with low incomes. 9 From the 1920s to the 1970s, NYC’s Bureau of Maternal and Child Hygiene maintained 68 baby clinics that provided this service as well as in-home nursing care to all birthing New Yorkers and greatly reduced the maternal mortality rate at the time; sadly, these clinics were closed during the 1970s fiscal crisis. 10 We are once again at a historic turning point where reviving such a program can address the current maternal health crisis we face.
Recommendations for NYS
This crisis calls for the creation of a network of community-based, publicly-funded neighborhood maternity care clinics that offer low-cost or free prenatal, postpartum, and newborn care.
Certified Professional Midwives, whose demographics are more diverse than current licensed midwives in NYS, specialize in community birth and are licensed in 37 US states; currently criminalized in NYS, CPMs must be given a path to licensure. 11 Support of legislation to legalize Certified Professional Midwives in New York State. (Assembly Bill A7898 / State Senate Bill S7078)
Studies have also shown that in-home community prenatal and postpartum care reduces costs and disparities, while improving outcomes. NYS can invest in creating an in-home prenatal and postpartum visiting midwife program for all births. 12
Fund and reinstate midwifery programs in all hospitals that provide maternity services to ensure access to midwifery care.
Write resolutions against NY District Attorneys pursuing criminal cases against community midwives.
Create a consumer advocacy department to assist midwives negotiating with private insurance companies and Medicaid to receive fair and timely compensation.
Create midwifery programs in upstate SUNY schools.
Create a midwifery workforce that reflects the demographics of the population served, NYS must also invest to diversify the midwifery workforce by facilitating scholarships and recruitment for student midwives from communities of color, LGBTQ communities, and immigrant communities.
Create a pathway for immigrant midwives to practice in NYS.
Recommendations for NYC:
Currently, midwifery education in NYS is largely undertaken by private universities with high costs. NYS can alleviate the burden of entry into midwifery programs through the creation of a “pre-mid” program at CUNY, that offers midwifery school prerequisites, and the creation of a Direct-entry Midwifery School at CUNY, where midwifery education would be more widely accessible.
Fund and reinstate midwifery programs in all hospitals that provide maternity services to ensure access to midwifery care.
Expand the in-home prenatal and postpartum visitation program to a larger population with more visits by nurses and include midwives in the visitation program
Creation of a network of community-based, publicly-funded neighborhood maternity care clinics that offer low-cost or free prenatal, postpartum, and newborn care.
Click here to read more about the need to expand and diversify midwifery care.
Create a central database of maternity outcomes and consumer advocacy platforms
NYS’ data on maternal outcomes is spread across many different sites, is challenging to access, does not include key information on outcomes, and is not updated regularly.
NYS and NYC must implement a central state-level and city-level data dashboards – much like California’s Maternal Data Center – that pulls rapid-cycle data every 45 days from a low-burden data systems to track maternal and neonatal health outcomes at all birth centers and hospitals including maternal, fetal, and child deaths; third trimester fetal losses; stillbirths; and birth-related injuries (including maternal injuries during childbirth). 13 Data should be broken down in detail, including by the birthing person’s race and ethnicity, and complaints and reports against hospitals and clinicians should be publicly accessible.
Following California’s Honor Roll example, based on the data, NYS and NYC can also create a publicly-accessible ranking system for birth-friendly hospitals that meet criteria for companionship and doula support during birth and at appointments; target Cesarean section rates; and epidural and episiotomy reduction rates, among other benchmarks. 14
While the recommendations of the 2018 Maternal Mortality Task Force are laudable, NYS and NYC must stay accountable and release an annual report on the progress of initiatives.15,16
Make all complaints and reports against hospitals and clinicians publicly accessible.
Create a public advertising campaign regarding the benefits of working with midwives and how to access midwifery care.
Create a midwifery advocacy campaign through advertising on public transport in multiple languages including Spanish, Chinese, Bengali, Russian, French and other commonly spoken languages in NYC.
Create a framework for doulas to publicly report incidents of abusive care from a provider, staff or institution.
Address preventable maternal deaths at hospitals
The majority of maternal deaths in recent years have occurred in hospitals, very often from preventable causes.
Recommendations for NYS:
Using California’s Obstetric Hemorrhage, Hypertension and Preeclampsia Tool Kits as an example, NYS can expand their implementation of quality improvement initiatives in all hospitals with practice drills and a statewide lecture series to improve responses to obstetric hemorrhage emergencies and prevent morbidity and mortality due to preeclampsia.17
NYS must also be accountable to the public for these deaths; it should instruct the Maternal Mortality Review Board to meet and review all maternal deaths, provide recommendations to the NYS DOH every year, and create an investigation team for all maternal deaths that releases information to affected families within 45 days of a death. 18
The creation of independent patient advocacy groups at public hospitals should contribute to an end to impunity for medical professionals who have had complaints filed against them.
As recommended by the 2018 Maternal Mortality Task Force, NYS must mandate that all NYS-based hospitals, medical schools, and healthcare worker training programs train medical personnel about implicit bias and medical racism, and create procedures for hospital staff to report abuses to someone outside of their institution with the authority/resources to meaningfully follow up.
Instruct the Maternal Mortality Review Board to meet and review all maternal deaths and provide recommendations to the NYS DOH every year.
Support expanding Medicaid benefits to one year postpartum. (State Senate Bill S1411A)
Support the New York Health Act. (State Assembly Bill 6058 / State Senate Bill 5474)
Support of the bill to inform maternity patients about the risks associated with Cesarean section. (State Senate Bill S2888A)
Creation of independent patient advocacy groups at public hospitals to end impunity for medical professionals who have had complaints filed against them.
Mandate all NY-based medical school and health care worker training programs to train medical personnel about implicit bias and medical racism.
Fund and reinstate midwifery programs in all hospitals and institutions that provide maternity care
Create a pilot project at a public hospital where patients are encouraged and supported in giving feedback regarding particular providers and experiences within maternity and reproductive care, including creating a “Whistleblower” hotline/mechanism for hospital staff to report abuses to someone outside of their institution with the authority/resources to follow up.
Recommendations for NYC:
Create an investigation team for all maternal deaths that releases information to the family within 45 days.
Establish reduction targets for Cesarean section rates with consequences for hospitals.
Require all midwifery and obstetric providers to inform clients of their Cesarean section rate.
Require all hospitals to inform patients of risks and benefits of electronic fetal monitoring and obtain informed consent.
Host Listening Sessions to hear directly from communities and clinicians affected by the racial disparities in maternal outcomes.
Expand family leave and keep families together
End mandatory drug testing of pregnant people and their newborns in all healthcare settings
Stop separating birthing people in prison from their newborn babies; allow incarcerated mothers and their babies to stay together in a community-based program for up to a year after birth. (See the Minnesota Healthy Start Act.)
Allow birthing people in prison to have access to their choice of care provider including midwives and doulas.
Write a resolution in support of expanding paid family leave to all domestic workers in NY State.
Expand the definition of family for paid family leave to include all those who workers consider family.
Raise the wage replacement rate for paid disability leave to 67% of a worker's average weekly wages, making it equivalent to the paid family leave wage replacement rate.
Expand enrollment period for paid family leave insurance for people who are self-employed. As of now, people who become self-employed must opt in within the first 26 weeks of becoming self employed; if they miss that window, they can still opt in but will have to wait two years before receiving benefits.
Increase the percentage of earnings that people receive while on paid family leave. Make the earning percentage received progressive, so that people who are earning less receive a higher percentage of their wages.
Remove paid family leave exceptions that currently exclude golf caddies, and teachers and public sector workers.
Increase representation of birth justice advocates at the executive governance level
Grassroots birth justice advocates have been consistently under-represented at the executive level in health departments. NYS and NYC must consult, employ, and partner with advocates to inform legislative and regulatory change if it ever hopes to make progress on the maternal health crisis.
Recommendations for NYS:
Increase midwife and doula representation in the NYS Department of Health Public Health and Health Planning Committee, Medicaid Managed Care Advisory Review Board, Minority Health Council and Rural Health Council and Taskforce on Maternal Mortality and Disparate Racial Outcomes.
Recommendations for NYC:
Increase midwife and doula representation at the New York City Department of Health and Mental Hygiene Bureau of Maternal, Infant, and Reproductive Health, New York City Board of Health, NYC H+H Board of Directors and NYC H+H Maternal and Child Health Unit.
Increase doula representation in the Maternal Mortality and Morbidity Committee of New York City.