The EngagED Midwife
The EngagED Midwife
From Equity To Advocacy: Caring For The Whole Patient
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What if the biggest driver of a healthy pregnancy isn’t found in a chart, but in a bus schedule, a work shift, or a zip code? In this episode, Cara and Missi pull back the curtain on social determinants of health and talk candidly about why late or no prenatal care rarely means a patient doesn’t care—and how midwives can meet these barriers head-on.
We break down the big five domains—economic stability, education, healthcare access, neighborhood and environment, and social context—and connect them to preterm birth, preeclampsia, and low birth weight. You’ll hear real stories from triage to community clinics that reveal why “proximity” isn’t the same as “access,” how immigration fears suppress visits, and how chronic stress leaves a physiologic mark. Then we get tactical: validated screening tools like PRAPARE and the AAFP Social Needs Screening Tool, the three fast questions that catch most needs, and scripts that normalize sensitive topics without stigma.
From there, we move into action. Warm handoffs, bedside calls, and referrals that put the follow-up burden on the system—not the patient—turn intentions into impact. We dig into practical documentation with Z codes that make populations visible, and we frame advocacy as a clinical skill that spans workplace notes, hospital policy, and conversations with legislators. Along the way, we draw a bright line between equality and equity and share simple ways to right-size support: flexible hours, interpreters, transportation help, and trauma-informed consent.
If you’re ready to turn empathy into outcomes, this conversation will give you tools you can use on your next shift. Subscribe, share with a colleague, and leave a review with the biggest barrier you see in your community—and how you’re tackling it.
Storms, Schedules, And Life Updates
SPEAKER_02Welcome to the Engaged Move Web Podcast. This is Missy. And this is Kara.
SPEAKER_01Welcome back. I know. I know.
SPEAKER_02Is it beautiful there today?
SPEAKER_01No, it's very, very, very stormy and they're calling for really bad weather. So it's kicking off. Um, I don't like to say the T-word, but in the Midwest, there's these things that happen in weather where the air swirls and it can destroy homes. Think Wizard of Oz. Think Wizard of Oz in Kansas. We are at high risk for that today. So I actually just called Julia and told her not to come home from college tonight that she should wait till tomorrow. And I know that's like the most Midwestern mom thing to do of like, don't be on the road. Because where what would you do? Where would you go?
SPEAKER_02We today we have yesterday's weather, like my sisters and you. Like we have 72 degrees and sunny and blue skies. Yeah. But it's been raining all week. And I'm actually super thankful for some sunshine. It's today is my last official day of leave. That's crazy. I have to go back to work tomorrow. And um it's nice to see a blue sky and sunshine and warm weather. Like I went outside in a sweatshirt and like long pants this morning, and I was like, oh my gosh, it's too warm for this.
SPEAKER_01Like, yeah, well, that's one of the problems with the risk here is that it's gonna be really warm today. So um, yeah, that's I can't believe you're going back to work and I'm a little anxious for you because you've got a lot of shifts in a row, but um, I know how excited you're gonna be to see your people.
SPEAKER_02Okay, yes. So that's the thing. It is equal parts. I'm so excited to see my work family, and I'm so excited to get back to doing what I do best, which is take care of care of moms and babies. But I'm also super nervous that I'm working a lot of shifts in a row. I'm also super nervous about not feeling 100% and still being really tired a lot of the time. And um, I had a long discussion with my MP about it this week. And so we have a strategy. Cool. And I think it's gonna be good. And if we have to shift some things, we will. But um yeah, it's gonna be a lot of like trial and error. And the good news is that my midwife sisters that I work with are going to not let anything bad happen to me. And I'm gonna make sure that I'm okay. And Betsy will be there. And so for those of you who listen to us and know Betsy, um, she is my uh my D sister, who's one of our charge nurses and CSLs, and so she'll be there to help take care of me too.
SPEAKER_01Yeah, that's so awesome. I just I know it's not the same, but I remember that first day back after my uh bed rest and C-section and six weeks to the day after my C-section, I remember going back and I just didn't, you know, I was I was a heck of a lot younger than I am now and healthy, but oh gosh, that energy was wiped out. So um, yeah, I hope you take it easy when you can. Do you have triage shifts or labor and delivery shifts?
SPEAKER_02I'm going back and forth. So actually, it's like every other. So I think I have four triage shifts and four like labor and delivery shifts.
SPEAKER_01Well, so maybe that'll be good because it'll be a mix of things, it won't be too much of any one.
SPEAKER_02And I don't really have anything planned Sunday, so I can sleep all day if I need to. Um but it's gonna be it. I'm just trying to go back at it. Like I've got some of my favorite foods in Nashville planned, and that will make it fun, and just like seeing people and like reconnecting, and maybe that will like ward off all of the other things.
SPEAKER_01So this is what's so crazy is I'm coming to Nashville this week and I arrive as you leave, and you come back as I'm leaving. It's insane.
SPEAKER_02When are you leaving?
SPEAKER_01Saturday morning, Saturday afternoon.
Today’s Focus: Health Beyond Clinics
SPEAKER_02Well, I'll be there Friday. So maybe we'll get to overload. Yes, maybe our lives will actually like overlap. So all right. Well, talk to me about what's going on today. What are we talking about today?
SPEAKER_01Well, we're gonna talk about what happens outside of our clinical walls. Um and this is one of those things that I think is super challenging, but we all know that so much of a person's healthcare happens outside of the clinic. It happens outside of the hospital, it's in their communities, it's in their homes. And so we're gonna talk about the social determinants of health and how um how we as midwives can assess that, why it's important to do so, and then what we can do when our patients are really struggling.
SPEAKER_02Yeah, this like strikes a chord with me in so many ways because of just the variety of places that I have worked in the variety of I think communities that I've served in 20 years as a midwife. And I know that that is the same for you as well. Yeah. But really talking about, I think, the why the social determinants of health matter, how are we going to screen for them, and then how we can actually like be part of the solution for our patients.
The Big Five SDOH Explained
SPEAKER_01Yeah, yeah. So I think one of the things we can do is start by just saying what are social determinants of health. You and I, when we went through our graduate programs, these weren't like specifically named as things. We knew that all of these things were important in our patients' lives. We knew they were important in our lives, but they weren't really called the social determinants of health, or sometimes you'll see them listed as SEOH. And there's five major ones, but we're gonna talk a little bit about some of those and how they interact. But the main things are economic stability. So does um do the individuals that we care for have job security? Do they have a lot of debt? What is the cost of living in their community? Um, what does it cost to stay healthy as well? Because there's that as well. So economic stability. Then we have access to education. What is their health literacy? What's their ability to navigate complex systems? Um, you know, just even you can tell a lot about a community based on their high school graduation rate, or what is the average, you know, highest level of education, that sort of thing. The third one is healthcare access. And that's not only do they have insurance, do they have access to medical care, but how far do they live from their distance from their medical providers? Um, do they have culturally concordant care too? So does my provider look like me kind of idea. The fourth one is neighborhood and the environment around them. So it's clean water, safe parks, it's do they live in a food desert or not? Um, we think a lot where I am about how rural areas may have a lot of difficulties because of access and community structure and that sort of thing. But inner city can look very similar to rural areas. You could have something right next to you, but you can't access it or that sort of thing. And then the fifth big one is social and community context, and that's all of our support systems. It's um racism and discrimination that can happen in our communities, and it's also the weathering that can happen because of those isms. Um, but that's kind of the big picture of the big five. You'll hear people talk about um access to childcare, family relationships, social inclusion, um, you know, employment rates, all of those different things as well, but they tend to tie into those big five um kind of buckets of things.
SPEAKER_02So that's our social. It's a lot to unpack, right? Because as you were talking, I was thinking, oh, I can think of a million applications to this, and I can think of like several examples of that and like why these are so important in healthcare. And it's interesting because I know some of our listeners and and and you know that I have been posting some barriers that I have experienced through my cancer journey as like a well-educated, well-resourced person. And um and I'm thinking through like this is why, right? People don't get better, and people um like mortality rate for some like diseases is is so high because of social determinants of health, and even like women of childbearing age, right? You don't have access to things, like we have high maternal mortality in non-white women. Um and so it's it all like in my you know, cloud of understanding of how healthcare works and how I think what my my understanding was before I had cancer, and now after I have cancer, like the before and after really has been clarifying for me. And as you're talking about this, I'm like, it really um hits home with some of the barriers I've encountered as well.
Real Barriers Behind “No Prenatal Care”
SPEAKER_01Yeah. Yeah. So I'm right as we're as we're talking about this, I've got pulled up in front of me this diagram from the United Way, and it's talking about these big buckets of social determinants of health and then how they can impact health. Um, and I think even as I read it, I'm like, of course it's the United Way. That's in our communities. That's all of our resources that are available to us. It's a safety net, right? Of what we're thinking about in our different communities, and that can look different in urban Kansas City, then that looks different than rural Hayes, Kansas, which is actually a pretty decent sized city, but it's uh it's rural versus a community of a couple of hundred people, you know, that is in a frontier area kind of idea. So um I think it's important to have some examples. And and you're right that, you know, you and I have worked in so many different areas and we've had to learn our communities in each of those places because it's not totally transferable when you move to a new community. You need to learn what's going on in that community and what resources are available. So let's do an example. So when we talk about employment and working conditions, if someone has precarious employment, like their instability, um, that sort of idea, that not only can impact their stress levels. We have a whole episode on stress and court is all right, but it also maybe they're in an unsafe working environment because they're having to work um in jobs that don't have the same protections that many of us have in big employment sites and that are you know governed by OSHA and that kind of thing. Um, when we think about, you know, um education, well, if there's reduced educational opportunities, are there fewer employment opportunities as well or lower paying opportunities? But also do they have good health literacy? And so we don't want to say that everyone in an area is um at risk isn't the right word. I'm trying to think of how to say this, but it doesn't mean a whole community is doing poorly, but we need to be aware of what the risks are and see if we have ways that we can shore those up for people and make their health more stable. But I love the idea that you were talking about of let's talk about like how does this impact midwives and the people that we care for specifically, and you mentioned it, increase morbidity and mortality, right?
SPEAKER_02Yeah, it's um, and I think that this the whole idea around this episode is like how can we impact our own patients, right? Right. I think we could have a whole long philosophical discussion just on social determinants, right? But what we really want to, I think make point attention to is like how can we be change agents, right? And how can we effectively understand what's going on with our patients? So some great examples are like for me, when I work in triage and a patient comes in with no prenatal care, who is clearly like in an advanced pregnancy in third trimester and has had no prenatal care. A lot of providers will be like, There's prenatal care everywhere. Why haven't you gotten prenatal care? So I think this is a great segue into some of these things that we should consider, right? Yeah. One of them is like you didn't get prenatal care because you don't care about your baby. You didn't get prenatal care because you don't have insurance, right? Those are like maybe you don't care or maybe you don't have insurance, and those are barriers, but there are so many other barriers, right? One of them could be language, right? I didn't have the right person to call to help me make an appointment. I don't speak English as my first language. Another could be transportation. I don't have a way to get to and from prenatal appointments, right? Um, another could be job, right? I have a job that requires me to work these hours and they're eight to five, and there's no prenatal care that I could get outside of eight to five, right? So just in this one case of like having a patient who presents in late gestation with no prenatal care, you can think of how many different social determinants may have played into the decision for someone to not get prenatal care. And I would be willing to bet that people who show up with no prenatal care, it's not because they don't want their babies.
SPEAKER_01I was just gonna say, it is not because they don't care at all.
SPEAKER_02Or that they don't care about their babies. Right. There are there are things, there are barriers that are standing in the way of them getting what they need. And and you know, another hot topic in the US is immigration. And so where I work in a very red state, I think that there is fear around seeking health care because of immigration.
SPEAKER_01There absolutely is. I mean, I have been a provider in clinics, an FQHC and a free health clinic that primarily served non-English speaking immigrants. Um, and depending on election timing, administrations, different things, our patient volume would crash. Like people would just not show for appointments, they weren't making appointments, they didn't feel safe coming to a place where they would have to present something about their identity or things like that. So you're a hundred percent correct in that we really it people are scared. And it's very rarely, very rarely that they don't care. Actually, yeah, probably more so that they care a whole lot.
SPEAKER_02Right. But I think that and and the then the idea I think that goes along with that is people who've got limited prenatal care. Why do they have limited prenatal care? Is it for those same reasons, right? They don't have a clinic that's close to them, they can't miss work, they don't have insurance, they don't have transportation. I think, you know, and and then like what's their education level and their healthcare literacy? Like, why do they understand why it's important that they be seen regularly through pregnancy? I mean, these are big things for midwives to be considering, especially depending on where you work.
Learning Your Community’s Resources
SPEAKER_01Yeah, I very vividly remember 20 plus years ago, and it was hot as heck in the summertime. And we had a patient come in by ambulance for a labor check and um spent hours, like really did not want to go home. She wasn't in labor. We had a hard time convincing her she wasn't in labor, but that she needed to go home. And her family was eating a ton of food out of the nutrition center and that sort of thing. And some of my fellow, you know, my colleagues were really upset about this. And I'm like, you know what? If she needed a couple of hours to rest in air conditioning, I'm cool with it, you know, or if that was their way that they were going to be able to feed their, you know, younger kids that came with them because we had graham crackers and apple juice in the nutrition center, let them have all the graham crackers and apple juice that they want. You know, like it's just some people are barely getting by. And sometimes we need to use our empathy to think about what we would do in that same situation? What would we do if we had such limited resources? And that was the only way we saw out. Or, but as midwives, I love the idea of you talking about us being advocates and not only thinking about how to access certain resources for our patients, but how can we make sure that those resources are available when they are, you know, like how do we advocate to get those things in place, to get those structures, to get those resources. Um, it's not always something that people feel like they have the skills for, but it's one of our core competencies, right?
unknownRight.
SPEAKER_02I I think too, as we think more about this, you also have to understand the idea that like chronic stress also plays a factor in this. And you mentioned this, like cortisol levels, et cetera. But like job instability, housing instability, food instability, all of that affects then our patients' outcomes. Yeah. Yeah. And so we also know there's really good research that says that it affects preterm birth.
SPEAKER_01I was thinking preterm birth, I'm thinking pre-eclampsia, I'm thinking low birth weight, you know, all of the things. We certainly can have big impacts on improving outcomes for individuals and communities.
SPEAKER_02Yeah. And then like when we're I guess another like kind of message that I want to make sure that our listeners hear is like, do you understand the community where you work? So like I have worked in a hospital-based 90% Medicaid um based practice. And I have worked in a 90% private pay bougie, right? Yeah. Private practice. Um, and now I'm in like a hospital system that I feel like is a safety net, right? With Vanderbilt, it's like where all the sick patients come. It's where, you know, a lot of the immigrant populations present to in Vanderbilt. But like in all of these situations, like, do you understand what's available? And I I could probably say with some honesty that I don't know all of the answers about all of my communities. But there are things that, like, do you understand that if like the food bank situation where you live? Do you understand resources for people who are unhomed? Do you understand the resources? And I've done really good about this one at Vanderbilt for the people who have substance abuse disorders, right? Um, the housing instability, like all of those, like what are the resources that are available? Like, um, what was the song on Sesame Street? Who are the people in your neighborhood? Yeah. I can hear it in my head, right? Who are people in your neighborhood? Right. And they're talking about the postman and the fire end, but I am actually talking about like who are the resources in your neighborhood and are you comfortable with being able to refer people to those places?
Screening Tools That Actually Work
SPEAKER_01That and then I also think about, you know, I had someone, a provider once at one of my clinics, and I think I was complaining that someone had been a no-show multiple times, and she stopped me. And this is one of those situations where I was so uncomfortable at the time. But then when I reflect back on it, I'm like, it was really good that she put me in my place. But she's like, Do you know what your patient has to do to get here for her appointment? And it was, you know, waiting on a bus and the but, you know, there's like snow. And is the is the bus stop plowed so that the bus can stop at the bus stop? Or is she even, you know, like how many, how many times, how many different transfers of that bus ride did she have to take to get to your clinic? And it, I I remember like a tear rolling down my. I'm like, oh my God, I didn't even ever consider that because I drove in here in my minivan and I parked in the parking lot and I walked into the office and it was no big deal. And similarly, she was like, Do you know what your patient has to do to get groceries? And it was, you know, you can only get what you can carry on your body at once. And if you don't have an elevator and you live on the third story, how many trips up and down the stairs do you have to take? And it really, I mean, in so many good ways, blew my mind. But at the same time, like, Kara, get out of your own way. Like, you're like we all live in our own little bubbles. And I may think my life is hard because, you know, I had to go to the grocery store versus ordering, you know, grocery pickup or delivery or whatever. But then I think about what other people have to go through to just be able to put food in their pantry or to be able to get to an appointment. And I love that you mentioned our hours, our our clinic hours may not match up with the needs of our community, that kind of idea. So I love that you raise this issue. Um, but then what do we do other than knowing our community? I think that's so important. What should what else should we do when people encounter issues in our communities?
SPEAKER_02Well, I think the most important thing for us to realize as midwives is like we are the ones who For lack of a better word, care than most. We're gonna be the ones who have the time, right? And the energy to sit down and decide and help our patients decide what they need and to be able to screen for whatever it is that like we can be helpful with. So like we are uniquely situated as midwives to provide this kind of support for our patients. Yep. Because we're not the ones, and this is so funny to me. This is like all coming again, coming full circle. Like my experiences with physicians versus the advanced practice providers that I've worked with over the last like 12 or 14 weeks in my own health journey is like the the NPs and the midwives are the ones who can like sit down with you and hold your hand and offer support in a way that you your physicians don't it's not that they don't want to, but they don't usually have time for. And that's important, I think, to consider. So I think it's important for us to understand that our patients have these things. They have limitations in social determinants of health that affect, you know, how they approach healthcare, that there are pieces of social determinants that certainly affect birth outcomes and affect women, but also that we are the people, right? Like we are the ones who can help affect some of this for our patients. So I think with that said, like we could probably talk some about maybe screening tools.
Warm Handoffs And Practical Help
SPEAKER_01I think, yeah, I that's exactly what I was thinking is first we have to actually screen. And so there are some validated and reliable tools that are mentioned. If you literally just type into Google S D O H assessment, there will be several that come up. But two of them are the most talked about. And um, we'll have links for you and share these with you. But one is the prepare, it sounds like prepare, but it's with an A. So P-R-A-P-A-R-E. And this is the protocol for responding to and addressing patients' assets, risks, and experiences. And it's about 15 to 21 questions, depending on the version that you get. And it's available in 25 languages, which is amazing to have that. Um, it's a really good tool, but there's another one that's really widely talked about, and it is the American Academy of Family Physicians social needs screening tool. They have a short form and a long form that's available. Um, and it does a really good job and is really suitable for various different types of primary care settings. But either one of those tools could be integrated into your EHR system. They are widely available on the internet. You can download the PDF and print it out and all of those different things. But those are like the valid, reliable, formal tools. Otherwise, there's three main questions that people will talk about if you only had, you know, you have a short amount of time, you have a shortcut. These three questions could be the three questions that you ask. And so one is that in the last 12 months, did you worry your did you worry that your food would run out before you got money to buy more? The second question is, are you worried about your housing situation? And the third question is, do you have reliable transportation to get to your appointments? So if you don't have the time or the resources to use those valid and reliable tools, those three questions could be your shortcut.
SPEAKER_02I love that. I mean, I love shortcuts anyway, right? Yeah. But I love the idea of like we can get to the crux of the problem, right? Food, housing, transportation. Big three, right? Now, are there other things that are important? Yeah. Sure. Right? Health literacy is important, insurance is important, um, those kinds of things. But big three things that really can help affect outcomes. Um, and I love a screening tool.
SPEAKER_01Yeah, I love one of the points also to think about is that instead of just saying, do you have enough money for food? You can normalize it for people and say, you know, there's a lot of my patients that have concerns about having enough money for food. Is this something that is also a concern for you? And so by normalizing it and saying, or, you know, even the I ask everyone these questions because these things are invisible and we can't just tell by looking at someone or something like that. By normalizing it, it really helps the patient to feel safe in that situation.
SPEAKER_02Yeah, and I think there are things now that I probably do differently than when I was a new midwife and integrating things into what I say, right? And making sure it gets said every single time, right? So just an example of that is is like when I'm thinking about consent for an exam, I always say, is it okay if I touch you? Right. That's the first thing I say, as well as like guiding somebody through that exam, right? But giving them words to stop, right? I might, that's just like um a script in my head now, like every single exam, every single patient, every single time. And so what the reason I bring that up is that I think it's important to be able to like, like you were saying, there's a couple of questions that I ask all my patients, and I just want to make sure that there's nothing that I that helps me gauge if there are any other resources that I can get for you, and then asking great questions. Yeah. So not that I want you to be a robot when you go into like your exam rooms, but I also think that there are if you script some of these things, you won't forget them.
SPEAKER_01Right. Exactly. Yeah. So in addition to screening, I think it's there's a couple of different things. One, you mentioned knowing your resources and then getting a warm handoff to those services would be really great. But then the other thing is that there are codes that you can use in your billing and coding that have to do with these types of situations where people are more at risk. Um, and so there are Z codes. Um, and you want to think about adding those to your documentation because the more we use them, the more you know, the insurers and so you may you may not get paid more for them. But it's helping to describe the communities that we care for and people take note of which codes are used. Um, and so again, not everything that we do with billing and coding is to capture more money, but there is benefit in helping people see the people that we're caring for and what risks they may have.
SPEAKER_02Yeah, I the billing and coding part, right? It's the stuff that I would always be like, this is the code. Back in the day when we had to do it by hand, do you remember we had to write it on the form? I can't remember.
SPEAKER_01Before we handed the Super Bowl over the case, circle all these different codes on a piece of paper.
SPEAKER_02We are really aging ourselves. Yeah. But okay, so what do we do? What's next? Like, what do we do if something goes astray?
Advocacy From Bedside To Capitol
SPEAKER_01Well, I mean, so there's a couple of different things midwives can do. We've taught, we've said the word advocacy several times. And I think that could be as simple as writing a note for your patient for their employer if there's a situation that we can help improve. They need rest, they need a chance to put their feet up, they need to do this, that, or the other. Now, I always say there's a risk in doing that because you want your, you don't want to, you know, work your patient out of being able to do their job if it's the only way that they can work. But there are at certainly advocacy things that we can do in writing letters, contacting employers, that kind of thing. But it could also be writing to your legislators, being an advocate at the community, state, county level, all of those different things. Because I think a lot of what we do is helping our legislators understand what the lived experience is in the communities that they serve. And as a healthcare provider, that carries a lot of weight when they hear, you know, you say, these are my patients, and this is what they're experiencing in your zip code, then they start to perk up a little bit and they want to hear more from you. Um, and you know, you don't have to be a physician to be able to be an advocate. You certainly, I think, you know, especially if you are a nurse, not all midwives are nurses, but if you're a nurse, remembering that that's one of the most trusted professions. And people really do listen when you tell them that you're a nurse and you have um input on a situation or you know, advice for them, or you're advocating on behalf of your patient. It's really important.
SPEAKER_02Yeah. So you've sort of talked about like advocacy in the office with how we code, like advocacy in our community, right? But I want to talk a little bit more about like just like one-on-one advocacy and what that looks like for our patients. And so it's really easy. And I again have experienced this. Like, here's a card, this is for you call. Yes, right. And I have mom brain, right? A lot of the time. And I have like high functioning anxiety anyway. So when you're handing me a card about a resource, I am probably, it is probably not connecting 100%. Um, and I'm like, oh, I might get to this, right? Actually, the thing I have found has been the most helpful is that when somebody hands me a card for a re referral, they say, Oh, I've already put this in. This is just for your reference. Somebody's going to call you. And I'm like, oh, burden taking the burden of responsibility off of me and putting it on the organization to contact me. So I think that if we have the opportunity as midwives to be able to say to our patients, like, I'm going to introduce you to this social worker, this social services person, you know, this resource that we have in the hospital or in the clinic. And they are going to help you do this thing to get um vouchers for food, this thing to get housing, this thing to get your medications paid for, right? Those the introductions that you make and the easing of the burden for the patient, I think goes a very long way into like not just being like, oh, here's a person you can call. Because honestly, saying that is also a burden that is a social determinant. Like, we know that like 95% of Americans have some sort of cellular device, whether it be like a flip phone or an iPhone, but there are some people who don't have phones.
SPEAKER_01Yeah, I mean, I'm even thinking as you said this, like, I love, I also love when someone's gonna call me to follow up on an appointment or making, you know, whatever that is. But maybe it's that if I have five minutes, why don't we make the phone call together right now? You know, that's another thing that we can do, is sometimes one of the best things that we have is our time and our energy and our presence. Um, and so just even, I don't know, it's hard to ask for help if someone else will help you do it and help you do the ask, it can be really nice.
SPEAKER_02Well, I'm like, I work night shift, so we don't have like our social work team isn't necessarily always there. And so we do a lot of finagling with what we can do to do what we can on night shift. I mean, I honestly called an Uber on my account for somebody to get home. I'm like, it's fine, I'm just gonna Uber them home. Like, she doesn't need to sit here all night just because she doesn't have a ride, and I'm not gonna make her sit in the lobby for however many hours until she can get a ride that just doesn't seem right. But I think you have to kind of understand like when people are also available to be helpful.
SPEAKER_00Yeah, absolutely. Absolutely.
Equity vs Equality In Care
SPEAKER_02Um, what else are we missing? Oh, so when we talk about advocacy, now we've sort of talked about advocacy like a one-on-one with our patients, advocacy in our community advocacy in terms of like political um alliances and the ability to just like advocate on a bigger level. I think what you have to think too about is according to ACM, in our code of ethics, right, that midwives should advocate for the rights of all people and that all people should have access to comprehensive health care, right? It's a very social justice-minded approach in our code of ethics as midwives. And so um, it doesn't matter where you live or where you work, right? It's understanding um equity and not equitable. Like, okay, so I do this all the time with my students, and I think it's this is a really great like learning lesson, right? Equality, the difference between equality and equity. Equality means that every single patient gets the exact same thing, right? And it doesn't matter what they need, what what barriers they have, it just means that everybody gets the exact same thing. That's equality. Equity is getting people what they need individually, like based on all of the things about that person, right? So you see, like the the visual is is you know um equality is when everybody's like standing on a box trying to look over a fence, but the box isn't high enough for some people, right? And equity is when the box rises or falls, just to make sure that everybody can see over the fence, right? And so for me, the idea is like, what are we doing to, you know, raise the box, lower the box based on what people need? Because the idea of equity is the idea that everybody gets what they need to achieve the same outcome. Right, right. And so in terms of midwifery, our job, the as I see it, is equity in healthcare, which is making sure that everybody has the access and availability to get what they need to have a safe outcome in terms of their healthcare circumstance.
SPEAKER_01Yeah, yeah. I love that example of looking over the fence. Um, I I can see the boxes that you're describing. We'll make sure we um put that image as a link in our um show notes as well. But it's equality isn't a bad thing, but equity is better, right?
SPEAKER_02Like, yeah, yeah, absolutely. So I think too, like when we talk about being midwives, it means with woman, right? Being with woman. And so that means being not just with them in a physical sense in certain terms of taking care of their babies or doing their well-bone exam or doing their breast exam or sending them for mammogram. It also means being with them in whatever it is that they need that affects their social determinants.
SPEAKER_01So yeah, it's clean water, it's housing, it's job stability, it's health literacy. I mean, it's all of those things. It's all of those things.
SPEAKER_02It's all of those things, and I think the keys here to this conversation are just understanding what all those social determinants are and and how they affect your patients, right? Like we were saying at the beginning of this episode, it may be different depending on where you live, right? But you could put five people in the exact same environment in the exact same city, and they all five have different social determinants that are affecting their their health care, right?
SPEAKER_03Yeah.
Ask The Hard Questions With Care
SPEAKER_02Um, or if you live in a metropolitan area, the the the individual nature of social determinants of health is beyond my level of comprehension, right? Everybody has something different, right? Yeah. Um and even as I have navigated my health journey the last few months, I have even recognized that there are things that are a limitation. And I'm a I'm a well-educated healthcare provider. Yeah. Um, and so that is something that is is interesting to me. Like even just navigating like portals, talking to people on the phone. Like, I'm like, how do people do this with full-time jobs where they're outside of the house? Like some of the things I can't, I just kind of like it, it's like a big like explosion cloud above my head because I just don't, I can't fathom how our healthcare system works for everybody. And I guess that's the the answer. The answer is it doesn't work for everybody.
SPEAKER_01Yeah. I think, you know, as you were talking, it also made me think that sometimes, like sometimes we're afraid to ask the questions because we don't want to make people uncomfortable. Um, I the example, I don't know why this is the one that I come to in my head, but I remember years ago, years and years ago, the midwives really wanted to have on our intake form whether or not patients had sex with men, women, or both. And our physicians were like, patients don't want you asking that. And we're like, does it not impact how we care for them? Like, maybe if we ask them, they'll tell us. Like, and we can take better care of them. Patients were totally fine with us asking that. They were there for sexual reasons or different things. But the same kind of idea of like, oh, we don't want to ask patients about their income or their housing or this, that, or the other. We don't want to make them uncomfortable. But sometimes they're relieved that you asked because that is the biggest stressor in their life. And that is the thing that's really impacting their health. And so I love the idea that we've just become more aware of all of the things that we can, all of the things that are taking place in our patients' lives that impact their health, but also how can we help them with all of those things that aren't prescribing a medication and ordering a test. Yes, exactly. What are all those other things?
unknownYeah.
SPEAKER_01Really meaningful things.
SPEAKER_02I also think that we probably have listeners who are thinking, like, this does not even scratch the surface. It does not. Yeah. This conversation does not even scratch the surface on social determinants. And if it's something that you're really passionate about, I really encourage you to like dive in.
SPEAKER_01Yes.
SPEAKER_02And dive in deep if this is something that you're interested in. Because I think every practice needs one person that knows all the things, right? Because if you have one person who's like, this is their passion and they want to be able to like know what's in the community, then that's the person that you're like, oh, I'm gonna call up Jane because Jane knows all the things about this particular topic and she's gonna be able to tell me what to do. Yeah. So be that person if this is a thing that like lights you on fire.
SPEAKER_01Yeah. Okay. So a couple of key takeaway messages. And um, I I know they're gonna sound like kind of trite, but they're little little bullets. But I want people to really take it in and think about this. But your zip code is a better predictor of your health than your genetic code is.
SPEAKER_02Wild. I can't I can't even wrap my head around that one.
SPEAKER_01Screening is an act of care. And that's everything.
SPEAKER_02That's screening for depression, screening for social determinants, screening for whatever it is that you're screening for.
SPEAKER_01Yep. We can't fix it all, but we can't ignore any of it.
SPEAKER_02I love the idea of like being a connector in this situation, right? Like I may not know it, but I am a really good connector of people. I can connect anyone to anything.
SPEAKER_01And I've got mad Google skills. I think it's underrated. I think it should be on my CV. I can find you something.
SPEAKER_02Yep. Yes.
SPEAKER_01Okay. Advocacy is a clinical skill. I would say it's also a moral skill, it's an ethical skill, it's all of those things, but it is a clinical skill, and we can't forget that. Yep. And then you're gonna this one's gonna speak to you too, because it does to me. Silence is a choice.
Key Takeaways And Final Reflections
SPEAKER_02I don't I I could just go on and on about this and about how like if we don't speak about the things, then they don't exist and that's not true. Um it's why, like, even in the labor setting, I'm so vocal about like, are we doing the right things for our patients? Because if it doesn't get said, it doesn't get heard, it doesn't get done.
SPEAKER_01Okay. So my last one, which is what you just said, is you have a midwifery voice, use it.
SPEAKER_02Yeah. This feels like very much like a Nike slogan, right? Just do it, just use it, use your voice. Right. Well, and okay, I need to I want to put a little like caveat on the just use it thing because not everybody is a type A extrovert, like we are.
SPEAKER_01100% agree. I would actually say I'm not a hundred percent an extrovert. I make myself do things I don't want to do.
SPEAKER_02I know, but I and since I've been moving, since I've been married to a 100% introvert for the last like 12 years, we are moving closer to each other on the introvert-extrovert scale. Now we're probably more like a 60-40 than we were on like opposite ends, right? But if you are not a big like, I'm gonna use my voice for all of the things, you can still quietly do things, but quiet isn't silent.
SPEAKER_01Yes, exactly. Exactly.
SPEAKER_02So well, I wish we could snap our fingers and make these things not be something that affects my wife food practice. Yeah, right. I wish we could solve the problems of the world. There are so many right now. I can't turn on the television because I find the world a very depressing place. And this conversation also just makes me so sad, right? For patients who who don't have. You know, the ability to get the health care that they need or that they deserve, right? Was it Mr.
SPEAKER_01Rogers that said we had to look for the helpers?
SPEAKER_02Was it Mr. Rogers? Yes, Mr. Rogers said look for the helpers. And Sesame Street is who are the people in our neighborhood.
SPEAKER_01Such good childhood lessons that serve us throughout our lives.
SPEAKER_02That's right. So I think we have to understand that a lot of what we do is clinical and that we do a lot of like we have we have to check off a lot of boxes in order to like say that we've done our jobs. But this the ability for us to understand these things kind of allows us to meet our patients where they are.
SPEAKER_00Yeah, absolutely.
SPEAKER_01And it helps us just be better community dwellers, parts of our community, thinking about even ourselves and our friends and our family. It's, you know, even if you just expand it beyond the people we care for in our in our exam rooms, in those hospital rooms, wherever we are, it's everyone else because we are part of the communities that we live in. We are we are stewards of the resources and we need to be advocates as well.
SPEAKER_02Right. So I think my my last little tidbit for you all as we like get ready to wrap up this episode is like the next time that you see a patient, like think about what's behind that patient. What are their stressors? What are the things that are affecting them outside of you know the things that we may just see? Um and and maybe dive a little deeper. I know a lot of we we think we don't have time, but we can we can make the time to ask at least three questions, yeah, and maybe um, you know, change an outcome for a patient.
SPEAKER_01I love it. I love it.
SPEAKER_02So good.
SPEAKER_01Well, thanks for being um part of this conversation. I think, you know, um you and I love chatting about clinical topics and pathofits and prescribing and all of the fun, cool things that we get to do and the not so fun things that we get to do as midwives. But I think this one might be one of the more important topics that we've talked about.
Share Topics And Connect With Us
SPEAKER_02Yeah, and it's been on our list for some time. So I'm happy that we got it out there and um we're always like looking for topics and what do you want to hear us talk about? And you know, drop us an email. Let us know on social. So thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again.
SPEAKER_00Take care.