“I’ve been putting out fires as they arise,” laughs obstetrician-gynaecologist Jesanna Cooper, referring to her work over the past months amid the pandemic in Birmingham, Alabama’s most populous city.
A well-known site of civil rights activism in the 1960s, Birmingham has recently seen mass Black Lives Matter protests. Almost 30% of its residents live in poverty and more than 70% are African American, who also face disproportionately high maternal and infant mortality rates.
Facing a lack of personal protective equipment (PPE) and constantly changing guidelines and recommendations, Cooper says she’s had an extra hard time trying to guarantee her patients’ safety – and rights.
She finds time to talk with me by phone on a Monday afternoon. She is on call, but it’s a quiet day after a rough couple of weeks. As a feminist and advocate for women’s rights, Cooper says she wants childbirth to be an empowering experience for every person who steps into the hospital where she works – a goal that coronavirus has made even harder to achieve.
As COVID-19 cases spread across the United States, more and more hospitals started introducing regulations to curb the rate of infection. Women giving birth were quickly, and seriously, impacted.
The World Health Organization (WHO) clearly advised countries that, during the pandemic, women still have the right to “high quality care before, during and after childbirth” – including clear and respectful communication, and a companion of choice during delivery. But this guidance appears to have been flouted in many places in the US and around the world.
In Birmingham, Cooper says she has fought from day one to prevent this and to uphold women’s rights throughout this crisis. “Our first fight was to explain that we were important,” she tells me, and to ensure that maternity ward staff were not overlooked in the distribution of scarce PPE.
The next challenge came when Alabama state officials recommended that hospitals restrict visitor numbers. Several hospitals did this, forcing women giving birth to make a choice between having their partner, a relative or a doula with them. Cooper’s hospital followed suit, but she fought back.
"I’ve been putting out fires as they arise."
Doulas, she says, are not licensed healthcare professionals, but they are “an important part of the care team”, providing support and comfort and acting as advocates for women during labour. Studies have confirmed that their work can result in fewer caesarean sections, complications and prolonged labours.
Cooper made sure that her hospital did not restrict doulas’ presence and treated them as part of the healthcare team, rather than as visitors.
Another fight was against the initial advice from the US Centers for Disease Control (CDC) – contravening WHO guidance – to separate women with suspected or confirmed COVID infection from their newborns. Cooper says several hospitals followed this advice (which was revised in May, to recommend such separations only on a case-by-case basis).
“It didn't make any sense to me,” she says. Especially during this crisis, she tells me, breastfeeding should be a priority, to strengthen newborns’ immune defences. “It seems really irresponsible,” she says, for measures to be “interrupting breastfeeding for those first few days and then sending the baby home with a mom who is less equipped to breastfeed.”
The WHO guidance explains that it is safe for mothers to breastfeed: there is no evidence that COVID-19 can be transmitted by breastfeeding and the active virus has not been detected in breastmilk.
"The birthing person is the head of the ship. The captain of the team."
Facing these COVID-19 challenges, Cooper’s approach has been to fight top-down restrictions by pushing for women’s rights and their informed decisions to be at the centre of her hospital’s policies.
“The birthing person is the head of the ship. The captain of the team. So what we needed to do was to have an honest discussion about what we know about COVID and what we don't know about it,” she explains.
At her hospital, even when a woman has COVID-19, she can choose not to be separated from her newborn. “Our paediatricians put together a good synopsis of what the options are, including guidelines on how to reduce risk,” she explains, and this information is shared with the woman who then decides.
This approach, says Cooper proudly, means that new mothers can “still maintain lactation and still get the emotional bonding that you get with the closeness that goes with breastfeeding. I think that is important for babies, and I think that's important for moms.”
The ‘childbirth rights’ movement
Under US law, every person has the right to informed consent for medical procedures. This means they have the right to get the information they need to make decisions about their health, including to refuse certain treatments. But rights advocates and researchers warn that even before the pandemic, these principles were being routinely undermined or ignored during childbirth.
Cooper is part of a small but close-knit network of ‘childbirth rights’ advocates that is trying to change this. Cristen Pascucci, founder of the group Birth Monopoly, says COVID-19 has only heightened their challenges, with new restrictions that she says were introduced “without any regard for evidence, rights, or the trauma that we're imposing on people”.
The Birmingham doctor has had growing local media coverage of her work – and her current campaign to transform part of her own ob-gyn clinic, across the street from the hospital, into an ‘auxiliary maternity unit’. This will cater for women with low-risk pregnancies to give supported by a nurse-midwife.
But this is the first time she is telling her story for a global audience. It offers a window into a longstanding crisis that predates the pandemic: the widespread abuse of women’s rights during childbirth. Her story also tells us how, largely off the radar, feminist doctors and rights advocates are creating change in their communities, despite the odds.
It hasn’t been easy. “I have struggled over the years with negative comments and pushback regarding the way I practice,” says Cooper, “and because of my gender and my failure to easily fit in with the Alabama medical community.” But she has found her place with current colleagues that are “more diverse and independent-minded”, who give her “more support than I have ever had”.
The feminist doctor has also found allies within Alabama’s religious community, which is “interesting, because we follow different paths to the same end when it comes to birth. We disagree politically, but both seek safer birthing environments for women with fewer unnecessary interventions.”
“Women who choose my practice span the spectrum of political views as well as religious ones,” says Cooper. They also come with different birthing plans, and that’s fine with her. Choice and consent are at the centre of her practice.
Regardless of whether women choose to have medicalised births, or c-sections, or home births, Cooper says the important point is that they understand all their options, including risks and ways to mitigate them.
“My job is to use my skills to help fulfill the plan that the birthing person has put in place and to give information to help them have the outcome that they want,” she says. Following this approach, she adds, means that “when things don’t go as planned, people still feel more comfortable with it, because they were part of the process, rather than a passive vessel.”
Psychology and c-sections
Cooper’s obstetrics training, she says, was “a very medicalised programme and I didn't get a lot of experience with unmedicated, low-intervention births”. It was only when she gave birth herself that she began to question what she’d learned. Once she was back home with her newborn, she started to have problems with breastfeeding that she could not explain from her training.
Before this, “I hadn't thought about how little training I’d had in supporting breastfeeding women and how the way we give birth affects lactation.” Afterwards, Cooper began studying these issues, and also midwifery, which she says opened her eyes to “how much is missing from the body of knowledge that we as physicians have when it comes to childbirth.”
Whereas obstetricians are trained to look for pathologies and diseases, she explains, midwives also focus on mentally preparing women for birth, including “being in a calm environment and approaching birth without fear”.
"The US is the most dangerous place to give birth in the developed world."
Cooper decided to incorporate midwives into her staff at the hospital – battling bureaucracy for three years to make this happen. Once it did, she says, the results were immediate. “We had more and more doulas coming in, more and more women giving birth according to their plans and in a more empowered kind of way, and then our c-section rates just started dropping.”
The number of c-sections performed is important because, as Cooper warns, “the US is one of the only developed nations that has a rising maternal mortality rate, and a portion of that is due to our rising c-section rate.”
The WHO recommends that c-sections are performed only when medically necessary, and states that the ideal rate of c-sections is between 10% and 15%. These figures are much higher in the US, and particularly in Alabama, where in 2018 almost 35% of births happened this way.
In just six months, the c-section rate for first-time mothers at Cooper’s hospital went from 25% to 11%, and the rate for all births from 33% to 20%. Reducing these rates was not her goal, however, and she describes it as a natural consequence of her approach, supporting women’s decision-making.
Her hospital offers elective c-sections, and they also offer women the option to wait and decide what they want closer to their due date. She thinks this had the biggest impact, as patients who are not in immediate distress often ask to wait, “and when you wait, you get a lot more vaginal births”.
The WHO also warns that C-section related “risks are higher in women with limited access to comprehensive obstetric care.” Even before COVID-19, many women in the US faced these heightened risks.
A 2018 investigation said the US was the “most dangerous place to give birth in the developed world”, with 50,000 women a year severely injured during or after childbirth, and 700 deaths.
Maternal and infant mortality rates are higher in Alabama than in many other parts of the country, and Cooper says “those disparities are even more pronounced if you break it down according to race.”
“When I started trying to make changes to my practice and to incorporate the midwifery mode,” she explains, “I was doing it mostly to support lactation and also to support women's rights, because it was important to me that women made their own decisions regarding how they gave birth.”
"I don't want to offer what I think is a really good model of care only to those who can afford it."
Everyone giving birth, Cooper insists, should have access to the same treatment, and it pains her that her approach is not more widely available. The COVID-19 crisis has only worsened inequalities in Americans’ access to healthcare, she adds, giving the example of home births.
Midwives for home births were only legalised last year and there are not very many of them in Alabama. They’re also unaffordable, Cooper says, for “a lot of women who are frightened of coming to the hospital” during the pandemic. She says they cost $3,000-$5,000 per delivery and must be paid in cash.
As hospitals around the US have become hotspots of coronavirus contagion, women need more safe places to give birth, the doctor says, and low-risk pregnancies that are unlikely to need special interventions or medications can be attended to by nurses and midwives outside of hospital maternity wards.
This is why she launched her campaign to transform her own clinic, across the street from the hospital where she works, into an ‘auxiliary maternity unit’. Her goal is to make childbirth safe and affordable – during and after COVID-19.
To do this, she needs the support of Medicaid, the government-funded health insurance programme that more than 70 million low-income Americans rely on. In 2018, it covered 50% of births in Alabama. “It is very important to me that we get Medicaid reimbursement,” Cooper says, “so that I don't offer what I think is a really good model of care only to those who can afford it.”
If Medicaid turns her down, the doctor has a plan B – which is turning to her ‘childbirth rights’ community for financial support for women with limited resources. Although still small, she says this community is growing and “we can fall back on each other when we're trying to make these changes.”
Beyond the pandemic, Cooper believes that “birth centres”, outside of a hospital setting, “are an important part of the solution for the problems we see in Alabama. But with COVID and the situation in the hospital, it became more urgent. We should stop waiting on this. Let's do it now.”