24 Keynote Ginger Breedlove

And now I have the great pleasure to introduce our closing keynote note speaker um Ginger Brid Breedlove who is a true midwiffery pioneer and innovator. Among her many accomplishments is as the past president of the American College of Nurse Midwives and co-founder of the first licensed freestanding birthing center in Topeka, Kansas back in the late 70s, the first hospital-based midrefree service in Kansas City in the early 90s. um and the founder and director of University of Kansas graduate nurse midwifery program. She's widely published in journals and publication um of speak much in demand speaker a principal investigator for over $5 million in research funds. She is a co-founder of um March for Moms with Dr. Neil Shaw and the found and its founding president. Um she now has founded and runs the US consulting firm Grow Midwives LI LLC to um scale and sustain midwiffery. She is a a true promoter and supporter of midwiffery and also an educator. Um I had the pleasure of teaching with her at Shannondoa University nurse midwiffery program for a number of years. Um she's also an author. She um editor and launched a best-selling book for new parents titled Nobody Told Me About That which is into its second edition. and she's also a um consultant and she learned skills at negotiation and management at the Harvard School of Business Mastery Certificate program in 2023. So with that, I will turn it over to you, Ginger. >> Thank you very much. Uh Katherine, can you hear me? I can hear you and you're spotlighted on the side so everything is good to go. >> Perfect. Perfect. Well, first of all, uh it's it's a true honor to be here today. Over the years, I have uh tuned in to virtual International Day of the Midwife. And I just want to say happy um happy International Day of the Midwife to everyone who's here with me this afternoon. A exactly 10 years ago today, I was in Nigeria as president of the American College of Nurse Midwives celebrating with Nigerian midwives on this special occasion and was able to witness over a week the incredible work uh they were doing uh for life sustaining skills of moms and babies. So, it's it's kind of a a full circle moment in many ways. I live in Kansas, uh, as you may have noted from the introduction, but I'm sitting in Washington DC, uh, getting ready to help participate in a two-day convening of Maryland, Virginia, and the District of Columbia as the midwives have come together to try to activate what we call little P and big P, uh, political issues and policy issues to to really fight for change, which is what today's a little bit about. But I want to I want to just start by saying I heard the opening keynote uh yesterday afternoon by Daniela who discussed a lot of resources that are crucial for midwives to know are available and to utilize them in the settings that they practice in. I also listened uh to Selene today talk about linking the midwiffery spirit to professionalism and it it sort of ties in to what I want to address today is how we connect our passion which which I would call our heart. I' I've been a midwife over 45 years with sort of the mental savvy that we need to begin to build to promote change. And I just listened to Alice. I could have listened to her all afternoon. I missed the last part of her presentation sharing the historical analysis of Hilda Sutton, a Cardiff midwife who went through uh decades of midwiffery service and talking about how the condition she worked in and how she transitioned um helping with really the National Health Service in England get established. And all that to say that the changes that we face are often triggered by conflict. Whether it's the conflict of war, which was being talked about a little bit, whether it's the conflict of um collegiality in our practice, the conflict of wanting to add evidence-based care to the families that we care for. And um it's not easy. There is no practice that I've ever worked in that is perfect. There is no team that is perfect. There is no setting that is perfect. And really begin to realize how we are the folks who need to promote the action and that really embracing conflict and I'll say it again, embracing conflict is your best tool for change. So, that's what we're going to talk about. I think I'm supposed to leave about 20 minutes for questions and answers. We'll see how that how that plays out. But, there are three scenarios that I'm going to give to you. These are all actual uh clients that I've worked with over the years. And we're going to talk about how these may be relevant or gerine in some way to the practices that you work in. Because what the focus is here is is what do we do about these barriers? How can we mobilize our midwifrey collective voices toward a call for action? Next slide. So the first scenario wh we went we went too fast there. The f wh wrong way. That's okay. We can we can do this. The first is about clinical practice and burnout. Um, wh somebody's advancing here a little too quick. Let's see if we can get the rhythm of it better. There we go. >> All right. >> All right. This is an established group of six midwives working in a hospital that average a 55hour work week. In the United States, most people think a full-time job is a 40hour work week. They worked along six physicians and following the departure of two of them in that large practice, the administration mandated that they were going to move them to a 65-hour work week to help cover the gaps in patient care. So, let's talk about the conflict. There was no corresponding increase in their salary or benefits. They were simply told, "Do it. That's what we do for each other. The patients need the care and it's your responsibility." The context for the midwives was they had not been given a raise for over two years and now they were being asked to work even more. And the concern you can imagine is workforce sustainability. How does that continue on in a way that doesn't lead to provider burnout? And as we know uh patient safety risks begin to elevate as our workforce begins to become exhausted. Next slide. The second scenario is about institutional policy and autonomy. And many of us in the US and I think probably around the globe listening to one of the presentations I heard are in situations where we know there's evidence-based care recommendations, but our institutions will not allow them, including nitrous oxide, which Hilda Sutton used in the home back in the 1900s. intermittent fetal monitoring instead of continuous EFM and offering water birth in institutions, not just water immersion in labor. What's the conflict here in this particular practice? Despite the support of their chief physician, the anesthesia department and many of the other physicians in the department remained vehemently opposed. What's the consequences? Rigid rules often drive the families towards another hospital setting or perhaps a community birth setting. And we are seeing a rise in free birth in our country. And a key concern could be loss of hospital market share. Always think about the hospital and the institution is following the money and truly the restriction of patient choice and autonomy with evidence-based recommendations. Next slide. And the third scenario is about professional politics and regulation. And we're facing this conversation here in the DC, Maryland, Virginia contingency that I'll be at over the next two days. A midwiffrey practice in any region or any country or even within a state that lacks uniform definition can cause inherent challenges. The conflict is that stakeholders of all types, families, payers, governmental organizations, licensing entities are confused by the different types of midwives that are practicing. The consequences can lead to title ambiguity which diminishes the understanding of the role. It can create barriers to the scope of practice. It can influence funding sources and create an amount of barriers that are really hard to imagine unless you're trying to practice through it. And the key concern then becomes the financial viability of the profession and the legal recognition of the profession. Next slide. Wh we're going too fast, guys. I I don't know how to help you here because I don't have control. But can we go back? So the themes of these three scenarios evolve to three key pillars. I I'll just say it that way. Economic devaluation is significant. The assumption that midwives in that first scenario can work excessive extra hours for free suggests that their time is seen as less valuable than other providers that are paid. Whether that's the physicians or the nurses that are employed. Clinical gatekeeping where hospital departments or institutions serve as gatekeepers restrict midwives from full scope practice and legislatively and legally without a clear identity of a midwife. We become vulnerable to who controls the funding, who allows certain things to happen within a state and confusion among the public. So on the next slide you're going going to see a book that I highly encourage you to think about purchasing. Next slide. Uh there is an anthropology professor whose name is William Yuri. He is without a doubt the most worldrenowned global negotiator alive today. His background is anthropology, but his work with the Harvard School of Law and School of Business has made him the negotiator that most presidents of the United States and globally have ever used, including successfully negotiating peace between North Korea and the United States. He's negotiated middle peace talks. He's done more than anyone could imagine unless you learn about him. And from his perspective as an anthropologist and the study of human behavior, he has created steps that I believe midwives need to learn and begin to articulate to use our voice to persuade others. And that's where we're going to go next is what are some of these steps that I believe needs to be as highly elevated as our prowess as practitioners. So what is possible? Next slide. Five. Wh we're going too fast. That just must be a super sensitive um super sensitive arrow here, guys. >> Ally, >> can we go back? >> There are >> Thank you. >> Um there we go. Here they are. uh addressing organizational conflict. And what that means is to not walk away from it, to acknowledge the conflict exists and instead of human nature trying to sort of have a step away from the tension and the emotional energy and the anxiety that conflict brings up to embrace it. Once you do that, you have to begin to organize meaningful data, come up with possible solutions, think about a bridge to common ground, and stay engaged with the other party or parties until you achieve multiple mutually favorable outcomes. So, we're going to talk about each one of these. Let's see if we can move it to just the next one, which is organizational conflict. I know you probably understand a lot of these concepts, but I think it's really important sometimes in the moment of frustration, anxiety, anger that we really realize this issue isn't between Katherine and I. You have to depersonalize the conflict. It's about the issue. It's not about the people. One of the things my husband um who's helped me really focus on a lot who who is an attorney and a mediator is always think about the position of the opposing party. What might be the plan they create against your argument? What could be a counter plan to their response? So you're always thinking two heads a step of what you're thinking, what the counterparty might be thinking, and how to respond to that counter. It's really important to avoid triangulating conversations because when you're not talking birectionally, you're getting the biases or the translation among a third party. So really having the conversations direct and not third party is essential. And sometimes that's very hard for midwives to do to get to the actual people who are the conversation uh decision makers. I love this phrase, listen then listen deeper. There's something always beyond what you hear the first time. And there's a couple strategies he talks about. One in particular is very easy to do called silence. Just be silent. You will be surprised how people fill that space very quickly. And the other's called mirroring. So if Katherine says, "I just think it's ridiculous." Then I would say, "It's ridiculous." and she'd go, "Yeah, it's ridiculous." And I'd say, "It's ridiculous." When you mirror that conversation three or four times, the person you're talking to then begins to give you more depth rather than creating anger. You're just reframing what they're saying. It's also important to look into the why. What is your why? Why are you moving this forward? And why do you think they're taking the position that they're taking? taking yourself out of the emotionalism and really thinking about the purpose of why this conversation's even happening. And the last is to move from destructive to constructive conversations. It's okay to say stop. You know, I think we need to stop. This conversation isn't helping us. Can we take a pause, maybe step out of the room five or t minutes and come back and be more constructive about how we're speaking to one another? Let's move to the next slide. The next principle is preparing meaningful data. I've spent years in high school and college in debate and it's the best thing that I think rounded me in midwiffrey. How do you how do you think about gathering the evidence to make your argument? We need to come clearly prepared to articulate clinical outcomes. At least in our country, it doesn't seem like outcomes means as much as money. It's like follow the money is the saying in our country, but clinical outcomes are important. Creating a list of shared goals is important. Finding evidence-based professional documents from every professional society in your country is important to demonstrate that you're looking at multiple lenses. Synthesizing peer-reviewed articles and providing them in the context of your presentation. This next one I think is really valuable because many of us in the research world tend to be qualitative or quantitative. But in reality, when you're trying to speak to change, numbers might provide logic, but stories provide the urgency. And in my time in advocating and uh spending time in Washington DC or my state legislative body, the stories seem to move people more than the statistics. And the last one is to think about predictive model thinking for that first example of the midwives that were being asked to work more. Here's an example. If we continue at 65 hours per week, there's a prediction that 50% of the staff over of the staff will turn over will leave within six months. And then what might be the responses to that? Next slide. designing possible solutions. These all are are really, I think, important to finding the shared goals or the win-win. So, how do you separate inventing from deciding? Every idea on the table should be brought forward without criticism to generate as many ideas as possible before even starting to articulate what might be the best one on both sides. Get everything out on the table. Nothing is nothing is improper. Shifting from a position to interest. Positions are what people say they want. Interests are why they want it. You want to understand the why. What is the underlying issue about the posturing of the opposing parties? Because the goal is to find a win-win. You want to find mutual gain here. You want to turn your adversary into your partner to solve the problem. And there are ways to do that. Dovetailing different interests. Solutions are not found because people are the same. But because they value things differently, one party might care more about cost while the other cares more about autonomy. So how can those fit together, especially in that first scenario that we were talking about? Next slide. One of the things Yuri really stresses and it's probably his most famous concept is to create a golden bridge. Instead of pushing someone towards your position, which only creates them to push back, you meet more resistance, you want to make it as easy as possible for them to say yes. And one of the ways to do that is to swarm the community. And what that concept means is that any conflict does not involve a twoperson relationship or two parties. There are always people around the issue that are influenced by the outcome and the decisions that are made. other staff, people who are involved in reimbursement, people that you are caring for, nurses on the unit, they are the community. And the community's voice is quite powerful when you bring them into this conversation. You also want to help people save face, right? It is okay to frame the victory as an evolution of your opposing party's idea. In fact, it's a great strategy so that there's a handshake at the end and you walk away satisfied and they think they're the winner. It's also important to involve people as much as possible in that in that the solution was from their advice, right? That's a little bit different than saving face. How would you handle the safety concerns if we're going to pilot nitrous oxide in this program? Are there ways and people we need to talk to that I haven't thought of? So, the goal here is to keep them engaged in this bridging conversation so you're not cut off with a no. That's the ultimate goal. The longer that you're in negotiation, the longer you're likely to get to yes. Next slide. So, here are three possible bridges from the scenarios that we started with. the practice hour scenario of the midwives working 60s some hours a week instead of paying them more versus working less. What about brainstorming or dovetailing options such as a flexible schedule, remote charting time, hiring predium or part-time staff to come in and help them during weekends or nights or peak hours. That is a way of beginning the conversation with possible solutions. What about the water birth policy? move from the position of no water birth to the conversation of safety issues for options for people to have a variety of protocols that might be something they want within the setting that's never had that you've never had before. So instead of answering the question about water birth, you create a safety protocol task force that may talk about issues far beyond water birth. And the last one is politics. Something we're going to talk about for the next two days here in DC. The types of midwives in our country and the pathways to education is quite complex. And I know we're not unique globally. But what does these types of midwives mean for patient access and improved outcomes? In this scenario, what could be billing codes and credentiing processes and state laws that could be rewritten and redesigned so that midwiffrey could be an option for more people that is sustainable. Next slide. So, how do you stay engaged in negotiation to the outcome? You go to the balcony. Literally imagine yourself going to the balcony and looking down. Look down on yourself, your team, and the opposing party objectively. Think about your emotions. What do you see in their posture? What are the tactics that are being promoted to diminish you, to discourage you, to intimidate you, and just look from above as what is going on here? Because there is a goal you want to achieve, and you have to avoid the drama to do that. You'll almost have to compartmentalize all of that stuff in order to stay focused on the goal and to stay engaged. And the other is step to their side. Do the opposite of what the other party expects. Instead of instead of arguing with them, acknowledge their concerns. Find small points to achieve a climate of orness rather than either or. So finding voice in midwayfree conflict. True confidence in negotiation comes from your internal preparation before you ever ever have your first conversation with the other party. All of those things that were outlined above need to seriously be thought about. What are your own practice needs and fears? Personally, as a group of midwives, as if you were a third party, we've talked to many midwife practice groups where all the midwives weren't ready to approach a difficult conversation because of fear of losing their livelihood and they're covering their family with their job and their health insurance. How does that impact the conversation? And the last one William Yuri talks about is the BATNA. How do you make a commitment that your happiness and self-worth do not depend on this deal? What is your best alternative to the negotiated agreement? Is it you're going to walk away? Is it you're going to give them an eitheror? Is it that you're going to give them your minimum line in the sand? What is it? If you haven't created the option for whatif, then desperation is going to interfere with your negotiation prowess and it's going to subject your confidence to a lot of vulnerability. Next slide. Courage comes from the ability to stay calm under fire. I think we've all experienced that in our midwifrey careers. and I practiced 25 years of full scope practice in a freestanding birthing center. We did home birth. I've worked in a tertiary care center. We all know what it's like to be under fire in the birth room. Being under fire in difficult conversations is not as easy for us to navigate. and going to the balcony often is what will calm us down to sort of rethink our approach and to be more strategic about those conversations we choose to have. The recommendation is a yes no yes structure. Yes, express your underlying needs and values or you will always harbor them in your place of employment. No means set a firm boundary on your values. you're not going to move from them or you're going to compromise. And yes, propose an alternative and a way forward and be willing to engage in the long run because there are consequences to not speaking up. And what we're seeing happen in our country is a high attrition of our midwives in less than five years from burnout, undervalue, not being paid, not being acknowledged, and they're ready to move move on to another profession. Next slide. Again, here's a reference of the book I'm uh talking to you about, possible, how we survive and thrive in an age of conflict. William Yuri has five authored books, multiple podcasts, TED talks, and his website is there. Next slide. There's contact information if you'd like to reach out to me. Next slide. We have a podcast that we launched in January. My colleague and I have called it the possiblest midwives which is really the framework that William Yuri works from and you can find us on a variety of um platforms in the United States. Next slide. I think the last thing I wanted to mention that's not there is we're actually having a conference in July uh that is virtual. There is no limit to registration and William Yuri will be the keynote presenter at our conference. >> So, Katherine, I'm going to stop there. >> Well, um we we don't need to stop. We just need to engage our participants and um see what's in the chat and ask any questions or comments that people may have. Yeah. >> Um, Seline is referring to the quote that actually you had in your presentation, Seline. Out beyond ideas of wrongdoing and right doing, there is a field. I'll meet you there. >> There. Absolutely. >> What a wonderful quote. >> Yeah. Absolutely. >> The fact that that you're willing to meet someone there is the key to that quote. Um, it's it's very difficult when we feel disempowered to find our control. And when we lose control, we fall into uh despair, helplessness, hopelessness, um anxiety, and tend to run away. So my hope is to give you tools to regain that control uh and to know that you have every right to speak out. >> Right. Well, car Carol wants to know a little bit more about what this conference is that you're speaking about. >> Sure. Um, if you go on the Grow Midwives website, you will find information about the conference. July, it's in July. I don't want to give the wrong date. I think it's the 23rd. It's all day on a Thursday. Uh, a virtual conference focused on the business and leadership savvy of midwives. uh we do not have clinical topics in this uh in this uh CME event but we have phenomenal national speakers uh who will be present. >> Great. Thank you. Um Linda in Scotland comments that nitrous oxide has been used by midwives forever in the UK both at home and in hospital. >> Yes, we know it's quite a challenge in the US. >> Right. and Jay Kaplan u I think she's referring to different types of midwives in that confusion is in many ways >> part particular pe pe pe pe pe pe pe pe pe pe pe pe pe pe pe pe pe pe pe pe peculiar or particular to the US >> although other countries have direct entry midwifery and nurse then midwife paths but we have a lot of paths here and it does create confusion for the public. All right. And um Jay Kaplan also comments, "Low volume rural practices. Midwives easily work that many hours and more, referring to a 65hour work week." >> Um it it is a challenge. It's not only midwives that are leaving, but a lot of physicians are are giving up abstetrics, especially if they've been in practice a while. Um, and a lot of our rural hospitals are closing because we can't find uh maternity care providers, >> right? Yes. And um and that brings up another point that Jay Kaplan is making or question. Um, Ginger, she'd like you to say a few words about when hospitals decide to pay consultants to come in and fix the financial mess the place is in and how this affects midwives OB services >> and what can midwives do when the consultant is not midwife favorable? >> Yeah, isn't isn't that a great question? It's actually part of my presentation tomorrow. Uh is the institutional barriers and how midwives in our country seem to not have readily available fiscal information. Meaning they don't know what their accounts charged are. They don't know what their accounts received are. They don't know what their work units are, which is terminology wvus in our country. And when midwives do not have access to this information, they cannot create the business case for their fiscal worth. And that is the key conversation. It's not patient experience. They know hands over heels with evidence we have better outcomes. The fiscal denominator is the issue. And many many times I would say some opportunities step one is to demand the fiscal information. If they're billing under your NPI, you have a federal right to get that information. And if it's denied, that's a problem. So, you have to gather that fiscal data and analyze it and be able to counter what they're saying with what you know to be true. In every group we have worked with in every setting you can possibly imagine a full scope full-time practicing midwife in the United States is charging about a million200,000 a year. >> Wow. >> And almost every midwife we've talked to has no idea that's what they're charging. Now there's a lot of more conversations that go into actual accounts received and then what's the cost for you to work there. But in the end, when we do these performers, midwives are averaging a profit margin of $300,000 per midwife. So if you have a practice of 10 midwives, do the math. Midwives are revenue generators, but they rarely know how to describe it or help others understand it. And that is a significant issue in our country. We don't have free health in healthcare in the United States. It's totally in uh an industry built on profit which is destroying our health care but it's also destroying our profession. >> Yes, agreed. Um Fatima has a comment about the statement she loves the statement listen and listen deeper. This can bring a lot of change in our profession. Not just listen and act but listen deeper before you act. >> Yeah. You know, where I I pulled that a little from was a nurse midwife whose name is Walia Early that works in Florida who I knew for a few years when I worked with her and we interviewed her on our podcast during Black History Month in February. And while Leah shared a lot about racism in maternity care in our country and specifically related to midwifery and families and one of the things Wahi really shared in a way that resonated with me is it's one thing to say midw midwives listen to women like I think that's the tagline still in the US but we need to go beyond that to listen beyond that and to really be able to provide provide an environment that's conducive to the deeper story. And when you're in conflict, you rarely know the entire story in the first encounter. It takes a couple exchanges to develop some kind of reciprocity in the conversation, trust, respect, where are we going in this conversation to begin to really listen to the next layer of why, right? Why is this the way it is? Why is this a barrier? And is there a pathway forward where we can begin the conversation? You might not find full resolution, but staying engaged in conversation is critical. Um, and you got to get past the first one or two.