The Expertise Across the Street

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A few disclaimers for this field note:

Along the way, I’m going to talk about getting obstetricians into systems where they can share their best selves, doulas into roles that expose the very best of what they have to offer without asking them to plug holes we created by thinning out the resources of health systems, and what I believe is real expertise sitting right next door to the people who seem to be looking almost everywhere else for solutions.

I’m approaching this and sharing with you from inside a profession that has spent decades practicing a version of postpartum care that much of American maternity care is only now beginning to imagine at scale.

When one of our clients in the midwifery world has a baby, the birth is neither the beginning nor the end of our relationship. It is a chapter of it.

After the baby is born, midwives do something called home visits. We leave our clinic or birth center and go to where the new parent, or parents, and baby are.

That may sound like a ridiculous explanation of a very simple concept, but I want to detail this, so you can perhaps imagine what this feels like.

We go into the home. We sit beside the family while they figure out breastfeeding or how they are going to feed their baby. We check blood pressure, bleeding, and healing. We weigh babies. We talk about sleep, pain, nutrition, mood, contraception, bowel movements for mother and baby, sore nipples, stitches, milk supply, and, in general, the extraordinary amount of bodily-fluid management involved in being home with a new human in the first few days after giving birth.

We talk about the enormous changes happening between the adults in the family, their relationship with this new baby, and, for the person who gave birth, the changes in relationship with oneself.

We are collecting hard points of data, giving tips and tricks passed along from hundreds of other families at hundreds of other visits like this one, and we are having structured clinical conversations. But we are also watching.

We watch how a mother moves when she stands up. We notice whether she winces or gets dizzy. We see where the baby sleeps and how the family is functioning around them.

We wait until the baby is actually hungry so we can watch an organically occurring, on-demand feeding. A hungry baby has behaviors worth observing, and the lactating body responds to the baby in ways that a staged or described feeding can miss. Watching that interaction in real time gives us important clinical information about feeding, physiology, and how this dyad is doing, together.

And we don’t do this once.

We do it several times, over time because postpartum is not an appointment. It is a transition.

And transitions are in motion. They move.

Now, don’t get all romantic on me. This is exhausting, whole-body work.

We sit on floors a lot. We pretend cats are cute. We wash dishes. We talk with partners, husbands, and new grandparents to ease their minds or give them concrete tasks that turn their fretting into action that serves the new family. We sit in a lot of traffic.

And we hold space for the realities of this time because a person can be doing beautifully on Monday and struggling by Tuesday afternoon.

Milk comes in. Sleep deprivation accumulates. Feeding changes. Blood pressure can rise. Moods can shift. A baby who seemed to be feeding beautifully may not be gaining appropriately.

Pregnancy does not necessarily end when the baby arrives, either.

The conditions of pregnancy can and do follow someone straight home from the birth center or hospital where they delivered. A mother who entered birth with undertreated anemia may emerge from it even further depleted, now trying to recover from blood loss while producing milk and functioning on fragments of sleep. Someone who managed glucose carefully throughout pregnancy may discover that the body’s needs have changed again, and she has to learn an entirely new rhythm of food preparation, eating, and monitoring at precisely the moment when preparing a meal for oneself can feel like an ambitious undertaking. Physical recovery postpartum is deeply informed by the level of physical activity during pregnancy.

All of these things, and much more, get pulled through pregnancy and birth into the postpartum period because physiology does not respect the administrative boundary we have drawn around birth.

It doesn’t care one iota. Neither does the family. And neither should the care.

Doctors have cared for hundreds of pregnancies. They know pregnancy. They know birth. They know postpartum complications.

But their professional experience has given them a detailed view of day one and a detailed view of day 42, and remarkably little access to the lived territory between them.

For midwives, that territory is not a void. It is not a chasm. It is not unknown. It is the work.

We walk into homes, or have people come into the clinic, many many times between day one and day 42. We behold the magnitude of change. There is joy, confusion, and dysregulation moving through each individual and through the family unit.

We notice the partner who looks terrified. We ask the questions that open the door to the things no one planned to talk about. We know how to name some of these things precisely because we see them rise up over and over again.

This is postpartum care as I learned it, and as midwives are actively practicing it right now.

At this very moment, while you are reading this, I promise you there are midwives in people’s homes, sitting on the floor, covered in someone else’s cat’s hair, taking care of a family in this exquisite way.

And yet, suddenly, everyone wants to redesign postpartum care.

For decades, the standard postpartum experience for the vast majority of American families has been remarkably thin.

You have a baby. You leave the hospital. Depending on what happened during the birth, you might have a one-week follow-up. If you had a cesarean birth, someone may check your incision. Then, often, the next substantial event on the calendar is the postpartum visit at six weeks.

Think about the postpartum care I just described.

Now think about that routine model.

All of us in obstetrics and midwifery monitor a pregnancy for nine months, hopefully, maybe even ten. Toward the end, we may see someone weekly, sometimes several times a week if additional monitoring is needed.

Then the baby arrives.

At the moment when a woman is bleeding, healing, sleep deprived, establishing feeding, undergoing enormous hormonal change, caring for a newborn, and moving through one of the largest physical and psychological transitions of her entire life, the infrastructure around her can suddenly go dark.

We built a system around the birth event.

We did not build one around the postpartum transition, and certainly not around matrescence.

In 2018, ACOG articulated a different standard on paper: postpartum care as an ongoing process rather than a singular encounter.

The maternal health world has since talked about earlier contact, additional visits, remote patient monitoring, lactation support, behavioral health screening, care navigation, and better ways of keeping people connected after discharge. Virtual care companies have sprouted up to create additional touchpoints and new ways of connecting with people between traditional visits.

But the plan on the ground, where most people actually receive care, has changed very little, if at all.

I suspect a large part of the reason is economic. The recommendation changed. The payment architecture did not.

For years, the model has been global maternity reimbursement.

In simplified terms, everything that happens across pregnancy, birth, and the postpartum period is bundled into a global reimbursement structure. Whatever you do within that space is generally reimbursed at the same rate, regardless of how much you do. There are exceptions for certain evaluation and management services and maternal-fetal medicine, but relatively few exceptions, and insurers have historically denied many claims that fall outside the global model.

That leaves very little financial room to build the kind of longitudinal postpartum care ACOG was recommending in 2018.

One of the clearest examples of what happens when the economics change came with reimbursable remote patient monitoring.

As soon as there was a billing mechanism, suddenly sending a patient home with a blood pressure cuff and maintaining an additional layer of clinical connection became operationally possible. The care idea was not new. The ability to pay for it, and the technology supporting it, was.

Beginning in January 2027, the global maternity payment model is scheduled to give way to a fee-for-service structure that makes individual pieces of maternity and postpartum care separately visible for reimbursement.

I am deliberately saying visible, rather than simply reimbursable, because I have thoughts about that.

I expect this change to create real movement.

I also expect payers to do their job and try not to pay. They will quickly begin looking for a ceiling: How many encounters? At what rate? Under what conditions?

I would not be surprised if the arithmetic eventually lands remarkably close to what maternity care is reimbursed at now under the global payment model.

But even if total reimbursement changes less than we hope, unbundling payment matters for a much more universally important reason.

It makes the individual pieces of postpartum care economically visible. And once care is economically visible, we can measure things.

That may be one of the most important lenses through which we can begin to understand why maternal health outcomes are so atrocious in this country. Once we can see the individual components of care, we can name them and quantify them.

The payment architecture will wind up spinning around and determining the care architecture.

I know we all hope that we come up with innovations and beautiful designs for care and then the payments follow.

That just doesn’t happen very often.

It is not how the system works, unless perhaps you are in the nonprofit world or working with an extraordinary MCO that is deeply committed to its members and helping them achieve their best health.

In recent weeks, I have watched very smart people create frameworks, diagrams, and infographics depicting what a more longitudinal, responsive postpartum-care model could look like.

And there is something genuinely strange, and slightly upsetting, about this.

Healthcare has a habit of searching vertically for expertise when sometimes it should search laterally.

We look upward and inward toward academic medicine, specialty societies, large health systems, consultants, technology companies, research institutes, and thought leaders. Those are all important sources of expertise. But they are not the only sources.

Because clinicians seated immediately adjacent to obstetrics can tell you what longitudinal postpartum care looks like.

Not theoretically.

Not as a proposed future state.

Not as a pilot.

As Tuesday.

Independent midwifery practices and birth centers have spent decades building systems in which postpartum care is longitudinal, relational, responsive, and delivered in the patient’s home and in the clinic. That does not mean every healthcare organization should copy a midwifery practice.

It means there is an existing system worth studying.

And that is a very different starting point from talking your ideas through with ChatGPT and having it produce an image for you.

Before you design the future, look sideways. Otherwise, we risk drawing speculative maps of territory somebody next door has been walking for decades.

There is a strange feature of institutional knowledge.

Expertise can be geographically, professionally, and institutionally close and still be epistemically invisible.

Obstetricians and midwives may care for the same families during the same biological process, sometimes across the street or next door to one another, and still operate from sufficiently different models of care that one discipline can contain knowledge the other barely sees.

The proximity of two professions does not mean they have equal visibility into each other.

Many of us entered midwifery after working as doulas, sometimes for years. That experience gives us intimate knowledge of the world and worldview of obstetrics. We have spent hours and hours in hospitals. We have watched how care is delivered and how systems are organized.

And there is another part of this that I want to name.

We receive patients every day who come to us carrying significant medical trauma from their obstetric care. They sit down and tell us their stories. For years, I have wished that the system that created this model of care got to sit next to me and hear those stories, too. There is a lot of pain in the gap between what people expected and what they experienced. Families are processing that pain while pouring everything they have into raising a new baby and becoming a family.

I want to be careful here because I have worked with obstetricians I love and value deeply. I am profoundly grateful for the work they do. This is not about an individual obstetrician causing trauma.

It is about a system that often prevents obstetricians from reaching their full capacity as physicians and as human beings.

They are constrained at every turn.

There often isn’t enough time for empathy. There often isn’t enough time for thoughtful education or the kinds of warm introductions and shared decision-making opportunities that a physician would prefer to engage in. There isn’t enough space for sorrow or joy, or the kind of relationship that allows a patient to feel agency in her own care.

Ask a doctor who they imagined becoming before they went to medical school.

Nobody says, I imagined working in a system that would make it almost impossible for me to be that person.

Nobody imagines a system that will squeeze out the very things that called them to medicine: curiosity, empathy, education, relationship, the opportunity to grow through caring for another human being.

So when I talk about trauma in obstetric care, I am not pointing at individual obstetricians.

I am pointing at a system that harms patients and constrains and even harms the people caring for them.

I don’t think we even know who our obstetricians could be if the system allowed them to become the physicians they imagined they would be.

I talked about a version of this before in a Field Note, It’s Not About the Money, Honey.

That piece explored our ability to see meaningful connections between things that do not initially appear related.

We create new ideas by seeing broadly enough to recognize what can be carried from one context into another. We notice a principle over here, a pattern over there, an approach from a field that supposedly isn’t even ours, and ask:

What happens if we bring that into this problem?

That is one reason narrow expertise can sometimes work against innovation.

If we only look for answers inside the intellectual boundaries we have already drawn around a problem, we dramatically constrain what we are capable of finding. Postpartum care is a particularly striking example because we do not even have to travel very far.

This isn’t obstetrics learning from geology or economics, although both have quite a lot to offer us over here in Healthcare World. The adjacent field, I hope, is obvious by now: independent, out-of-hospital, community-based midwifery.

Now I’m going to digress because I can practically hear someone thinking:

Great. Let’s do it, JLO. Let’s hire doulas and go!

I am an enormous believer in doula care.

I was a doula. It is how I became who I am in this profession.

Doulas bring continuity, presence, advocacy, preparation, knowledge of the birth environment, and sustained attention to the person moving through it. One of the most important things I learned as a doula was to teach parents how to ask great questions, be quiet while they asked them, and then help them work through the answers. It was, and remains, an extraordinary coaching role.

And today, differently from when I was in the role, the advocacy doulas provide has raised the level of accountability for everyone.

We need doulas.

Some of the trauma I talked about earlier is reduced because a doula is in the room.

But we need doulas to be doulas.

We have developed an unfortunate habit in American maternal healthcare of identifying a gap and asking a doula to stand in it.

Continuity problem? Doulas. Navigation problem? Doulas. Trust problem? Doulas. Disparities? Doulas. Postpartum support? Doulas. Doulas have shown us that all of those things can be improved.

But our deserved enthusiasm for doula care risks becoming a way of asking one profession to compensate for failures in the rest of the system.

I have seen physicians post things like, Thank goodness the doula noticed the patient was bleeding heavily and went to find someone.

And my reaction is:

Where was the staff? Why was that the doula’s job?

I have been the doula in situations like that.

It is horrifying to recognize an emergency when you are not the person credentialed, equipped, or responsible for managing it. And then somehow, once the thing is discovered–it’s on you to make the system respond. I know what it feels like to stand in that position with blood literally running down onto your shoes and no one but you in the room.

So to the doulas who have noticed the bleeding, seen the change, recognized that something wasn’t right, and raised their voices when no one else was responding: thank you.

I know women’s lives have been saved because doulas were watchful and willing to speak up.

But those moments should make us ask what the system is relinquishing onto them.

A doula’s continuous relationship with a family should be baked into maternal healthcare. At this point, I think it is nearly non-negotiable.

But doula care is not centered on clinical evaluation and management. And it shouldn’t be.

A doula is not there to clinically assess postpartum bleeding, interpret changing blood-pressure patterns, evaluate healing, assess the physiology of lactation, or integrate what happened during pregnancy and birth into an evolving postpartum clinical picture. (Some doulas carry additional credentials that expand their scope, but those are different roles.)

That distinction does not diminish doula care.

I hope you really hear that. I want to protect it.

The answer is not to value doulas less. It is to stop using their extraordinary value as an excuse not to build the clinical infrastructure around them.

Washington State offers an extremely uncomfortable illustration of how distorted the incentives can become.

Under the current Medicaid structure, comprehensive doula reimbursement can reach about $3,500 per pregnancy under a global-style reimbursement model, while global reimbursement for a clinical maternity episode for obstetric or midwifery care has been about $1,750.

I am not arguing that we should pay doulas less.

I am arguing that we should look carefully at what our payment system is showing us.

We have simultaneously under-reimbursed clinical maternity care and increasingly looked to doulas to fill gaps that this very underinvestment helped create.

The imbalance is felt by obstetricians and midwives.

And it is not repaired by asking doulas to become something they were never trained to be, or by paying them less.

We cannot solve a workforce-architecture chasm by overburdening the profession standing closest to the hole.

If we are serious about redesigning postpartum care, which I hope we are, the interesting opportunity is not deciding which profession can absorb more of another profession’s work.

It is asking what becomes possible when each profession is able to contribute the expertise it actually has.

This is where my work in interprofessional education and collaboration shapes how I see the problem. We have spent years talking about team-based care in healthcare and the major innovation we’ve come up with is a white board in the patient room that lists provider names and the care plan that is supposed to be accompanied by a meeting of all parties with the patient, together. But genuine interprofessional practice asks something harder of us than putting names on a white board or adding different credentials on the same organizational chart.

It asks us to understand what each profession uniquely knows and to build a system in which people can practice fully within that expertise without being asked to stretch beyond it simply because the system has a hole.

And this is where we have to be careful not to flatten these professions into versions of one another.

Midwifery is not miniature obstetrics.

Obstetricians are not high-risk midwives, and midwives are not low-risk obstetricians. Doulas are not less-clinical versions of either one. These are distinct professions with different training, different scopes, different ways of seeing, and different expertise to bring to the same person.

The opportunity in interprofessional care is not to blur those distinctions. It is to understand them well enough to build a system where each profession can contribute what it uniquely knows, and where the family benefits from all of that expertise working together.

That means the obstetrician does not have to provide every layer of care.

Neither does the ARNP. Neither does the midwife, doula, care coordinator, or physical therapist.

The design question becomes:

What would it look like to create postpartum care in which each profession can practice to the top of its scope while remaining genuinely interwoven with the others?

That is a different problem from simply adding visits. It is also why I am so interested in the reimbursement changes coming to postpartum care. If the payment architecture creates room for more touchpoints, the next question should not be how to squeeze additional encounters into the model we already have so that we can bill for them.

It should be: What care architecture does this new flexibility make possible?

Some connections will be in person. Some can happen in the home. Some will be virtual. Maternal-fetal medicine expertise can increasingly enter a patient’s care remotely. Virtual maternal-health platforms can create additional touchpoints between traditional visits. Remote monitoring can extend clinical observation beyond the walls of the practice or the home.

Technology matters. But technology does not answer the underlying design question. We still have to decide who should be connected to the patient, when, for what purpose, and what each person should be equipped to notice.

There are accessible ways to organize this that respect professional scope, use reimbursement intelligently, and give families substantially more continuity without requiring obstetricians to suddenly start making postpartum house calls.

This is work I spend a great deal of time thinking about through the lens of interprofessional collaboration because we do not need another infographic showing that postpartum care should be more connected.

We need to start designing the connections (IRL).

If healthcare turns its gaze sideways to midwifery, I do not think the most important lesson will be to schedule more postpartum visits. More appointments can still produce fragmented care. The deeper lesson is continuity. When we walk into someone’s home three days after she gives birth, we do not encounter a blood-pressure reading, a depression-screening score, a lactation problem, or an incision. We encounter all of them together, in the context of a whole human and a whole family and a whole community.

And because we knew this family before the baby arrived, we have something else healthcare systems often struggle to create:

A baseline.

We know what this person looked like when she was well. We know what she worried about during pregnancy. We know what mattered to her. We know what was difficult about the birth.

And that baseline knowledge saves lives. That is not merely relationship-based care.

It is information.

Continuity creates context. Context makes signals easier to see. And seeing signals earlier changes what becomes possible.

A feeding problem can be addressed before it becomes a weight-gain problem.

A rising blood pressure can be caught before someone becomes critically ill.

A mood change can become a conversation before it becomes a crisis.

A recovery problem can be identified while it is still relatively easy to solve.

That is what good postpartum infrastructure does. It does not wait until the end to ask how everything went. It does not point fingers when things do not go as planned.

It creates enough connection along the way to know how things are going, and to have the right care, at the right time, from the right professional.

I have worked closely with physicians where we deliberately decided to collaborate to address some of these issues.

And one thing came out of that work that I want to leave here for the systems thinkers to consider.

When we work together, we catch things early.

And sometimes, when we catch things early, we cause a readmission because we get treatment on board before a full-blown crisis exists. This matters deeply because we may be preventing downstream health consequences, including organ damage that could follow a person for the rest of her life. But those preventions that convert into readmissions create a measurement problem. We need a way to count that as a positive find. Right now, the readmission can be counted as a ding against the providers. I bring this up in a lot of meetings because I genuinely want to find an answer.

If you have one, please tell me.

I want healthcare to redesign postpartum care.

I want better reimbursement. I want more technology. I want remote patient monitoring and earlier intervention and better coordination and more support for families.

We need to build all of it.

But before we declare the future state, let’s have the intellectual humility to study the people already living in parts of it.

Go to the birth centers. Talk to independent midwives. Study their postpartum schedules. Go on a home visit with a midwife. Ask what they look for when they walk through the door. Ask what happens on day three, day seven, week two, week four. Ask how they know when something has changed. Ask what their model allows them to see. Not because midwifery has every answer. It certainly does not.

But because innovation is not only the production of new knowledge.

Sometimes it is the recognition of knowledge your existing frame has taught you not to see.

And that is what Harvest the Signal is about.

Before you build, look around.

Before you invent, look adjacent.

Before you draw the map, find out who has already walked the territory.

And when the people next door have spent decades learning the terrain, maybe invite them into the room before you decide what the future should look like.

Seen this pattern where you work? Hit reply and tell me. That's the harvest.

Want a bit more? Listen on Apple Podcasts or Spotify for One More Signal about this topic.