Revised: Plugging into this important work

Midwifery, Reflections on racism and oppression in midwifery

To find out more about how to get connected to this important, ongoing work, visit the following sites describing more active initiatives, committees and task forces:

AROMidwifery Facebook page

Equity in Midwifery Education for educators, administrators, staff, and students

National Association of Birth Centers & Clinics of Color Facebook page (NABCC)

Social Justice and Birth by NACPM (National Association of Certified Professional Midwives)

ACNM’s Diversification and Inclusion Initiative (American College of Nurse-Midwives)

Black Mamas Matter: A Toolkit for Advancing the Human Right to Safe and Respectful Maternal Healthcare

The National Association to Advance Black Birth (NAABB) formerly known as International Center for Traditional Childbearing (ICTC)

Changing Woman Initiative Native American-centered women’s health collective

National Latina Institute for Reproductive Health

Intersex Awareness

Healthcare in the US, Intersex, Midwifery, Midwifery students, Reflections on racism and oppression in midwifery, Social Justice

 

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Written by Kelsey Chieko Babb for AROMidwifery Blog

As we approach Intersex Awareness Day observed on October 26th, I felt compelled to contribute a post highlighting some of the excellent education out there that aims to increase visibility of intersex folks, as well as speak to the campaign to End Intersex Surgeries. Intersex people are those born with a range of biological sex characteristics that may not correspond to being distinctively male or distinctively female (4Intersex, 2018). The Association of Ontario Midwives (2018) reports, “people with intersex traits are a diverse group that face discrimination and often experience trauma when engaging with health care providers, beginning in infancy.”

Historically, cosmetic genital surgeries were performed before 18 months of age for the perceived benefits of early gender assignment (Intersex Society of North America, n.d.). Intersex children were generally not made aware of their condition and their medical histories were withheld from them by their doctors. Intersex treatments and surgeries in this manner are not only an inappropriate and unethical medical practice, it is an infringement on the child’s right to bodily autonomy. According to the United Nations, carrying out these procedures without consent violates human rights.

The United Nations states medically unnecessary genital surgeries should not be performed in light of the many serious, negative impacts they pose on children. The lasting and irreversible nature of repeated surgeries and treatment to intersex children can cause permanent infertility and lifelong pain, scarring, incontinence, loss of sexual sensation, and psychological trauma (United Nations, 2018). Conformation to the gender binary is not a basis for subjecting invasive procedures on otherwise healthy intersex children.

Many medical associations, such as The American Academy of Family Physicians (AAFP) have taken a firm stance against unnecessary intersex surgeries. Their policy reads, “scientific evidence does not support the notion that variant genitalia confer a greater risk of psychosocial problems” (AAFP, 2018). Unfortunately, even the most research based recommendations don’t always make it into current medical practices right away.

Where should midwives stand on these important issues regarding respect for bodily diversity? I believe that just as midwives safeguard and advocate for the rights of birthing people, midwives must also position themselves to advocate for intersex child autonomy. Midwives, as the baby’s primary health care provider, perform the newborn exam and care for the first six weeks of life. Midwives have a role in the identification of a visibly intersex newborn in their care. Therefore, they can hold a great deal of influence by simply addressing the misconceptions with parents, holding space for emotional processes, and further discussing the recommendations for care. Midwifery providers are well poised to help families navigate informed decision making, participate in medical consults, and make necessary referrals for the care of an intersex baby.

“Intersex babies are beautiful just the way they are”
-United Nations

Please consider showing your support by signing a petition to End Intersex Surgery at Lurie Children’s Hospital in Chicago!

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Learn More Here! Resources for Intersex Education
InterACT Advocates for Intersex Youth
Intersex Justice Project
#4Intersex
Human Rights Watch and interACT Intersex Feature Video
United Nations Free & Equal

 

Resources for Article:
American Academy of Family Physicians. (2018). Genital surgeries in intersex children. Retrieved from https://www.aafp.org/about/policies/all/genital-surgeries-intersexchildren.

Association of Ontario Midwives. (2018). AOM position statement on intersex child autonomy. Retrieved from https://www.ontariomidwives.ca/aom-position-statement-intersex-child-autonomy

Intersex Society of North America. (n.d.) What’s wrong with the way intersex has traditionally been treated? Retrieved from http://www.isna.org/faq/concealment

United Nations Free & Equal. (2018). United nations for intersex awareness. Retrieved from https://www.unfe.org/intersex-awareness/

4Intersex. (2018). Intersex 101: Everything you need to know. Retrieved from http://4intersex.org/wp-content/uploads/2018/07/4intersex-101.pdf

Understanding Barriers to Healthcare Among Resettled Refugees

Midwifery, Midwifery students, Reflections on racism and oppression in midwifery

Written by Olivia Kimble, Student Midwife at Bastyr University for the first class in the Midwifery Care series

The life of a refugee is inarguably more difficult than most healthcare workers probably imagine. It is easy to forget about the challenges refugees face because many of our own communities are made up of homogeneous, native-born citizens. Citizens are more likely to understand and exercise their access to healthcare through private or community clinics, or, as a last resort, the emergency department. In contrast, a refugee has to overcome additional obstacles before accessing healthcare, and then might only have access to racist and xenophobic providers.  

The people displaced because of civil war, political oppression, and economic instability face many challenges and traumas in their attempt to seek liberty and safety. Once these people have made it to a new location, usually illegally, they face hurdle after hurdle trying to establish a life. Refugees are subject to sweeping employment discrimination because they cannot speak the native language (or are easily recognized because of an accent), are undocumented and therefore cannot demand better working conditions or livable salaries, and cannot setup informal businesses without attracting law enforcement (Langa, 2011).

Langa (2011) reports that “by and large refugee women live in fear, and feel dislocated, and displaced” (p. 2). As a provider it’s important to recognize how a refugee’s health status is tied directly to their plight as a refugee. Understandably, refugees are probably not the most reliable patients because they have to spend such an inordinate amount of time finding or creating livable income to support themselves and their families.

What some health care providers might describe as uncooperative or difficult patient behavior was clearly visible in The Spirit Catches You and You Fall Down (Fadiman, 1997). Lia’s parents are continually seen as disagreeable because their Hmong customs and ideas conflict with American ideals of personal responsibility and hierarchical submission to their doctors’ orders. The Lee family relied on state assistance and thus did not have the freedom of movement, time, and resources that the doctors expected from their patients. Foua’s culturally-motivated rapt attention to Lia and her determination to carry her, clothe her, feed her, and love her regardless of her physical health status created a strange tension between her doctors who were also trying to care for Lia in their own American, individual way (Fadiman, 1997). Unfortunately the doctors who treated Lia were somehow immune to the family’s plight as refugees and saw their battle for economic security as a hindrance to their care instead of informing how to best care for the Lee family.

Refugees are often among the hardest working people in any country because they have to be. Finding a new home, creating economic stability, and rebuilding a community are monumental tasks to undertake even with good health. Unfortunately, needing and seeking healthcare as a refugee might be as costly and dangerous as remaining ill.

References:

Fadiman, Anne. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York, NY: The Noonday Press.

Langa, M. (2011). Women empowerment: A case study of a refugee women’s group at the Centre for the Study of Violence and Reconciliation. Retrieved from http://www.csvr.org.za/images/docs/Other/women_empowerment_a%20case_study_of_a_refugee_women_s_group_appendix_e.pdf

Written by Olivia Kimble, Student Midwife at Bastyr University for the first class in the Midwifery Care series

Health care in the US’ biggest colony

Healthcare in the US, Midwifery students, Reflections on racism and oppression in midwifery

By Tamara Trinidad-Gonzalez, Student Midwife

First, I must confess that making this post has taken longer in time and energy than I had anticipated. Writing about this subject and all its layers is a huge trigger of all the frustrations that living in a colony entails.  Pointing out one preexisting factor of why the care system in Puerto Rico has been so inefficient is not that easy as there is no such thing as one factor. This is more a cascade of effects, in fact, a very complex one than an isolated situation. I will try my best to explain it.

All this inefficiency goes back to the origins of our colonial politic situation (starting in 1898), which opens the biggest gate for Puerto Rico to not being treated equal as the other US territories and jurisdictions. In addition to this, the predominant political corruption for decades, have been a fertile ground to make this a major disaster. You may have heard already through the media that there is a huge, and unfair $73 billion debt that Puerto Ricans are being blamed for. Economists keep studying this socio-economic issue and it is evident that the colonial control over the economy of Puerto Rico has contributed to create this crisis. This crisis is affecting the daily quality of lives of Puerto Rican’s especially when it comes to educations and health. Alvarez and Goodnough (2015) emphasize that the disparity of federal fund is responsible for $25 billion of the total debt because the government of Puerto Rico was forced to borrow money to be able to keep the Medicaid program running. They also explain in this article that the misery of Puerto Rico’s health care began in the late 60’s with the initiation of the Managed Care health system and the Medicaid Cap placed by the U.S. Congress for all of its territories. The managed care health system in Puerto Rico has proven to be very ineffective for decades. This type of health care plan only works in favor of the insurance companies and not to benefit the people nor the health care providers.

There is a huge disparity of federal funding available for Puerto Rico in comparison to what is available to the rest of the US jurisdictions and territories.  The federal funding and commonwealth funding need to be equally paired, but the Commonwealth pocket does not have the capacity to pair sufficient amounts so, substantially less amounts of funding are given to Puerto Rico. The problem is that in Puerto Rico, more than 60% of its residents (which used to be 3.5 million people before Hurricane Maria), receive Medicare or Medicaid. Thus, the funding allocated is just not enough to properly care for the health of people. Alvarez and Goodnoug (2015) make a comparison of how much funding is given to two other states equal in population, but wealthier than Puerto Rico, and I created this table to see it better.


State/ Jurisdiction Population Medicaid funding/year
Puerto Rico 3.5 million $373 million
Oklahoma 3.49 million $3 billion
Mississippi 3 million $3.6 billion



Because of this situation, we (Puerto Ricans) grow accustomed to hearing of doctors leaving the island motivated for better income and work conditions. There are great physicians in Puerto Rico (PR), so they are being offered an income that is 3 or 4 times what they are earning, with moving expenses covered, health insurance, vacations and even with their liability insurance paid. To have a clearer idea of the magnitude of this problem, an article from 2016, a year before hurricane Maria, was already revealing the dangerous migration of Puerto Rican physicians to the mainland. From 2006 to 2016, around 5,000 physicians had stopped working in PR. By the summer of 2016, there were only 9,000 physicians with active licenses. And with a population of 3.5 million people, this meant having like 5 doctors for every 2,000 people. The chaos that this causes in the daily lives of Puerto Ricans is very present and evident.  Some examples of this is when patients must wait many months to have an appointment with a specialist, or when someone that is sick, does not get treated for something simple, and then dies; or when there is an urge for a treatment and people opt to travel to the US to get the needed treatment.

If this already sounded like a shortage and terrible health conditions, after hurricane Maria, a massive amount doctors left the island, abandoned their practices and their patients and many hospitals closed. This includes OBs which left many women without adequate prenatal care. Although the midwives stepped in to help as they could, they lack the resources to help everyone as they would like and deserve.

In conclusion, although we pay the same Medicare and Social Security taxes as the rest of the US, we are not treated equally. All this produces an unbalanced health system that is not fair for the people nor for the health providers that are compromising their humanity and their Hippocratic Oath.

References:

Alvarez, L. & Goodnough, A. (2015). Puerto Ricans Brace for Crisis in Health Care. Accessed online at https://www.nytimes.com/2015/08/03/us/health-providers-brace-for-more-cuts-to-medicare-in-puerto-rico.html?_r=0

Bodenheimer, T. & Grumbach, K. (2012). Understanding Health Policy: A Clinical Approach, 6th Edition. McGraw-Hill, New York, NY.

GFR Media (2016). Peligrosa fuga de miles de médicos. Retrieved from https://www.elnuevodia.com/noticias/locales/nota/peligrosafugademilesdemedicos-2225024/

Written by Tamara Trinidad-Gonzalez, Student Midwife at Bastyr University originally for a class in the Professional Issues series: Health Care Systems and Health Policy

Not Only Roseanne Barr is Racist

Reflections on racism and oppression in midwifery

To my fellow white feminists, if you’ve been thinking of yourself as less racist than Roseanne Barr as you consume recent news, I suggest you check out this great article: https://www.dailykos.com/stories/2011/5/22/957012/-
One thing I get out of the above article is the particular challenge that emerges in working to dismantle racism with and among people (feminist, but also progressive) who think of themselves as caring, good people. Because their identities are so wrapped up in thinking of themselves as good people who want to serve others and do their part to make the world a better place, there can be an extra block to understanding that as white people we are necessarily racist and have unearned white privilege.

Do you see this phenomenon in the organizations where you work or volunteer?

-By Kristin Effland, CPM, MA

Owning the Shadow: White Patriarchal Culture in the Preceptor and Student Relationship

Midwifery, Midwifery students, Reflections on racism and oppression in midwifery

by Anonymous

I wish I were writing a happy fluffy blog about how great my apprenticeship was and how wonderfully supportive my preceptors were on my journey to becoming a midwife. Instead, I am writing this heavier piece. Hopefully it can shed some light on a problem and therefore help the movement along so that more people of color can more easily become midwives, and in turn serve populations who are currently not widely served by midwives of color, or the midwifery model of care. If we want to eliminate racial disparities in birth outcomes, we need more midwives of color, and culturally competent midwives in general.

I am a Chicana apprentice midwife. I recently worked at a birth center run by two white midwives, serving mostly white pregnant people. I am fairly accustomed to working in majority white spaces, and attending majority white institutions. I am comfortable in my skin and able to navigate many spaces, including majority white spaces. This navigation includes exiting those spaces when need be. I am grateful for the opportunity to attend births and apprentice with seasoned midwives. I mostly had great experiences and learned so much in my time there. And, with these preceptors, I also experienced a series of hierarchical and racialized interactions, which I call everyday racism. It is most often unconscious, rife with micro-aggressions, and subtle and overt displays of power-over. However unconscious, the role of everyday racism is to maintain the racial status quo. It eventually cost me the apprenticeship, and it cost me the opportunity. There will be other opportunities, but I point this out because this is something that people of color (POC) have to face again and again when we enter majority white spaces, with white supervisors, professors, and employers. What we face is to swallow the racist injustice and stay, or leave the opportunity, or to take-on the racism directly — all of which come with a cost to us personally and professionally.

I am writing this as an alternative to silence. While I chose not to address this on a personal level with my former preceptors, I write this to address a systemic problem that I see as pervasive in many institutions, of which midwifery institutions and birth centers are not immune. Upon reflecting on the problematic interactions with my preceptors, I decided it was going to be best for me to resign from my apprenticeship. Leaving was better than to stay working in the stress of those conditions. Leaving was definitely better than to stay and to take-on the massive unpacking of the everyday racism in their communications and behavior. It would have been a nasty job to unpack, and it could potentially have long lasting and far reaching negative impacts for me in the small community where we live. Unpacking racism with white women, especially ‘progressive’ midwives, is a massive job. It is painful, unrecognized, and unpaid work, and it’s a job that I will not volunteer myself to do this with these women. It is sad, but true. I reserve the right to not put myself through this kind detrimental action, because let’s be honest, however gentle you may be in your communication, how many people are actually thankful when you point out their participation in white supremacy and patriarchal culture? These people are rare. And if the person is your instructor, employer, or any person in a position with power to compromise your grades, employment, or apprenticeship, then the stakes are high.

Everyday racism is an issue which must be addressed in the wider community of midwives. I have witnessed everyday racism before and know it well. Most people of color know it well and have experienced it. We have experienced everyday racism in schools, university, at our places of employment, in hospitals, on the street, in our interactions with police, in our government, in businesses in which we are patrons, and in birth centers with midwives. As people of color in these situations where our livelihood or our very lives are at stake, our confidence becomes viewed as arrogance, disrespect, or worse, is viewed as a threat. Most of us have learned when we may need to dampen that confidence for appearances, to be “humble,” speak in whitewashed tones, keep our heads still, our faces without too much expression, and apologize when we have nothing for which to apologize. Most of us have played the game at some point or another. But where has that gotten us? It may temporarily save a grade, a job, but what life is that? I suppose it depends on what is at stake.

I know that my experience is not an isolated event in midwifery culture because of the mostly white landscape of midwives, and the smaller percentage of midwives of color in the U.S. I know from speaking to other students and midwives of color that they have had similar experiences. Until we commit ourselves to unlearn the lifetime of learning racism, then we are doomed to repeat and reproduce it. Unless these uncomfortable conversations are being had, and the inquiry, study, and practice to unlearn racism is in place, then we can be assured that the structures of patriarchy and white supremacy are being replicated. We all have implicit bias, and it is past time we get to know these unconscious biases really well. This is our work. It is your work. It is my work. It is our work together.

I am glad to see that this years 2017 MANA-CAM conference, “Collaborate,” is addressing some of these issues. Among other very important workshops, there are break out sessions entitled: “Whiteness and Racism in Birth in the US,” and “How to Use a Racial Equity Toolkit for Decision making in a Predominantly White Organization.” There are sessions centering women of color: “Indigenous Gathering: Ancestral Knowledge Keepers,” “We are the Gardeners, Leadership Training,” “Black Women Birthing Justice,” “Reclaiming Indigenous Midwifery: Stories of Honoring Ancestral Knowledge, Resisting Medical Colonization and Returning Birth to Native American Communities,” “The Giving Voice to Mothers Study: Communities of Color Speak of Disrespect and Inequity in Access to Birth Options,” “Centering Collaboration to Improve Equitable Birth Outcomes,” and “Birth Justice 101.” This is a wonderful line up of workshops and it makes me hopeful of real change.

The topic of racial equity in midwifery is vitally important, especially as it pertains to women of color working unpaid apprenticeships for white preceptors. This dynamic is fertile ground for historical trauma, and current racial patterns to be repeated and reproduced. That being said, it could also be a great opportunity for ever growing awareness, education, creating and sustaining equitable structures and relationships. Midwives need to be having trainings and making policy to address racial equity in midwifery culture and midwifery institutions. However, until this culture changes, for my following apprenticeships, I will be seeking out midwives of color for preceptors, and consider white preceptors only when they have truly made racial equity explicit in the student/preceptor relationship, and in their midwifery practices.

The following demographics matter because they illustrate the landscape of the midwifery field in which apprentices of color are entering. While the statistics I found do not wholly represent the midwifery workforce, they do offer a general picture of the racial make up of midwives in the United States. The department of Education released demographics in Race & Ethnicity by Degrees Awarded in Nurse Midwife for 2015. Here is the breakdown: White 250 (76.7%); Black 21 (6.4%); Unknown 19 (5.8%); Hispanic 18 (5.5%); Multiracial 8 (2.5%); Asian 7 (2.1%); Hawaiian 2 (0.6%); Native 1 (0.3%). While this is the racial demographics of Nurse Midwives for 2015, it offers a general picture of the racial make up of midwives in the U.S. We also have demographics from NARM. While it is not comprehensive, because only 33% of the CPM’s sampled, (that is 706 of 2,106 CPMs) completed the survey, it is still informative. From the 2016 NARM Job Analysis Survey Comprehensive Report:

Question #26: What is your ethnic background:

614 of the 706 respondents (approximately 87%) identified themselves as white or Caucasian. Of the remaining 13%, 31 respondents identified themselves as multi- ethnic, 18 respondents identified themselves as Hispanic and/or Latino, 9 respondents identified themselves as Black/African American, and 5 respondents identified as American Indian, Alaskan Native, or Hawaiian. This was an optional question, so 18 respondents declined to identify their ethnicity.

I bring the issue of everyday racism in midwifery forward because it needs to be brought into the light, understood, and dismantled. Everyday racism is not as easy for white people to see as compared to the more obscene racism, which many consider to be ‘real racism,’ or the real threat. Racism is often seen as ‘out there,’ not right here in our very own unconscious thoughts and actions. Everyday racism is often more subtle. There must be dialogue, but even more importantly, there must be a commitment by white midwives to reflect upon implicit biases and educate themselves, otherwise these dynamics will continue to unconsciously persist. If we are to have more midwives of color, if we care to serve pregnant people of color with cultural competence, and ultimately to effectively address the problems of racial disparities in birth outcomes, then the dynamics of everyday racism of preceptor to apprentice in midwifery culture must cease to exist.

Following are some examples of the how these dynamics have seeped into and are embedded in midwifery culture of today. The dynamic is present in the hierarchical culture between preceptors and students of any color. It is present in the bullying that is pervasive. It is present in micro-aggressions towards student of color. Often there are unspoken expectations of apprentices, which can change on the whim of preceptors. It is present in the replication of the racial status quo and historical tropes which are repeated. It is present in the centering, and directing of the narrative that some white midwives do when there is disagreement or conflict with a student of color. It is present in the white centering, or derailing of conversations about race. It is present when problematic behavior is called out in writing or in conversation and is met with claims of being “attacked.” (For example, this essay could be construed as an “attack” on white midwives.) It is present in the displays of power that preceptors hold over students if they should want to keep their apprenticeships. It is present in the implicit bias that is not acknowledged, and actively denied. It is present in the projection that racism is a problem of people of color, and not a problem of white people. That’s a radical idea: racism is a problem of white people.

There have been research papers and discussion of bullying in midwifery culture, (See the work of Marivette Torres and Marina Valenzuela Farrell). I understand that white student midwives also experience patriarchal hierarchies with their preceptors. To make a distinction, what makes these interactions racialized is the white history and current day of whites oppressing people of color. While white students and students of color both face the bullying and hierarchal structures of patriarchy, students of color are also confronted with the racial hierarchic structures of white supremacy. White people can no more easily extricate themselves than people of color can from the history and current day structures of patriarchy and racism. Just because one does not see their participation in actively reproducing these structures, it doesn’t mean they are not participating, or responsible. Without the tools and implementation of oppression, there is no oppression.

I’m exhausted by the conversation always being about how POC are wronged. We know. And if you’ve been paying attention, you know too. As Erna Stubble puts it, “Even when the history of POC is told, white violence is erased, and the consequences of historical injustices is minimized. White people do not connect themselves to [the present, or] history.” I’m ready to move on to the next phase of the conversation which centers and addresses the wrong doing, the wrong doers, and the silence — let us address the deafening silence. Part of this silence is because, as I mention above, many white people do not see oppression as their problem, and so they are not invested to learn how they contribute. While white supremacy is prevalent, it is pushed so deeply into the collective shadow. It is disgusting, and yet, as Robin DiAngelo says, we are ALL swimming in its waters. While some are burdened by it, others unconsciously benefit from it, and so they are not as inclined to do anything to change it, nor do they see their silence and inaction as collusion. If we do not take responsibility and actively practice racial equity, then we most assuredly are replicating unequal structures. Let that sink in. Midwives do not consciously choose this, so let’s not unconsciously choose it.

Maternal mortality rates in the United States have been on the rise. Do we blame the mothers? Not unless they are Black or brown, (see Ina May Gaskin). When we have the dire situation where Black mothers are dying from pregnancy related causes in rates of up to 4 times more, (and in some places 12 times more), than that of their white counterparts, and regardless of income or education, the problem is not because of Black women and Black people. When Black babies die at rate of 2-4 times higher than that of white babies, the problem is not because of Black people. So where does this devastating problem arise from? There are so many layers of this crisis, and they all have roots in the devastating effects of white supremacy.

NARM and some midwifery schools acknowledge the problematic dynamics when Westerners, and more specifically when white students go to Black and brown countries to study midwifery. In the same way, so must we acknowledge the problematic dynamics that can, and do arise when Black and brown American students work apprenticeships for white midwives. Even though we are all Americans, the legacy of colonialism, and the inherent hierarchies are residual and present in these relationships today. Let us make this dynamic explicit so that we may address the problems with honesty, transparency, and policy. The midwifery schools and organizations that oversee students and preceptors can make policy to address this issue, advocate for students, and ensure racial equity and access to midwifery education, and apprenticeship.

Midwifery is about women being with women, it’s about midwives helping pregnant people and their families. If there is any group of people that has the capability to actively address this issue, I hope it would be Midwives. To eliminate racial disparities in birth outcomes, we need more midwives of color, and we need culturally competent midwives in general. We need the path to becoming midwives to be accessible for all women, and without racial obstacles. Importantly, white midwives need to become conscious of their positions in white supremacy, to commit to not participating unconsciously, and to consciously take this on as their individual and collective work. We have to fully own all of the layers of this problem to get out of this dire crisis.

Racial Disparities Persist

Healthcare in the US, Reflections on racism and oppression in midwifery

Despite the national Healthy People objectives established every ten years for the last three decades by the Office of Disease Prevention and Health Promotion, maternal and infant health indicators in this country continue to demonstrate a significant need for improvement, particularly among racial and ethnic minorities (Mathews & MacDorman, 2006).  In their call to action to the public health profession, Garcia and Sharif (2015) commented that “the health consequences of living in a racially stratified society are illustrated by a myriad of health outcomes that systematically occur along racial lines, such as disproportionately higher rates of infant mortality” (p. e28).

Two areas of concern, in particular, have been identified as leading health indicators with regard to maternal and infant health in the US: all infant deaths and total preterm live births.  These two health indicators, in addition to many others, provide clear examples of the health disparities faced by people of color in the US.  The rate of infant deaths (within the first year of life) is more than doubled for black or African American babies when compared to white infants (10.8 per 1,000 vs 5.1 per 1,000 in 2013).  Infants of persons identified as American Indian or Alaska Native are also disproportionately affected (7.6 deaths/1,000 live births in 2013) (Mathews & MacDorman, 2006).  While overall infant deaths have been decreasing, the health care disparities outlined above have persisted since at least 2006, the earliest year analysis by race/ethnicity is provided publicly by HealthyPeople.gov.  Preterm birth rates (before 37 completed weeks gestation) are also consistently found to be higher for mothers who are black or African American (16.0%), American Indian or Alaska Native (13.1%), and Hispanic or Latina (11.3%) when compared to white mothers (10.5%) in the US  (data from 2013).  While the causes of health care disparities and inequities are multifactorial, racial disparities are a well-documented factor.

NOTE: The phrase ‘maternal and infant health’ is used above due to its widespread use and recognition in public health literature.  The use of this phrase is not intended to exclude or ignore the health issues faced by transgender and genderqueer persons who may not identify as mothers.

References:

García, J., & Sharif, M. Z. (2015). Black Lives Matter: A commentary on racism and public health. American Journal of Public Health, 105(8), e27-e30. doi://10.2105/AJPH.2015.302706

Mathews T. J., & MacDorman M. F. (2010). Infant mortality statistics from the 2006 period linked birth/infant death data set. National Vital Statistics Report, 58:17, 1-31. Hyattsville, MD: National Center for Health Statistics. Available from: https://www.researchgate.net/publication/46146499_Infant_mortality_statistics_from_the_2006_period_linked_birthinfant_death_data_set .

If All Lives Really Mattered

black lives matter, Healthcare in the US, Midwifery, Reflections on racism and oppression in midwifery

The main strand of the alternative birth movement in the US which has been lead primarily by white, middle class women since the 1970s often conceptualizes their work as a pursuit of liberty and happiness.  Publications and participants characterize the movement as ensuring a woman’s right to an empowering pregnancy and birth experience.  The concepts of one’s rights are inexorably tied to notions of liberty, but much like the historical roots of freedom (and lack thereof based on race and gender) in our country, rights have been granted by the powerful only to those deemed fully human and deserving of happiness.  Happiness and rights are permitted by the systems of power currently in place only in forms still confined within the status quo.

Oparah and Bonaparte (2016) point out the ways in which the birthing consumer’s right to empowerment narrative has emerged and succeeded in public discourse precisely because it doesn’t challenge the deeper social and economic forces at work which serve to subjugate and ignore the most vulnerable pregnant people (15).  Indeed they argue that “legislators opposed to feminism…and to left-wing countercultural tendencies have found it possible to support the consumer right of (white, middle-class) mothers to ‘purchase’ the birth experience they desire”  (14).   

Empowerment is presumed by many in the modern white, middle class midwifery movement to be a desirable goal leading to happiness and therefore to be pursued in the name of all women.  The tendency in the second-wave feminist movement to claim to speak for all women while not taking “black women’s concerns seriously” (13) has emerged throughout the movement for reproductive rights.  In 2003, the Feminist Majority Foundation and others agreed to change the name of the protest march they were planning in response to criticisms from diverse stakeholders that the movement needs to broaden its perspectives and goals.  Black women and others on the margins, it was argued, are not available to simply protest for their right to safe abortion.  Instead, the diverse organizations courted wanted recognition that they are literally fighting for women’s lives.  As a result of the broad coalition formed, the March for Women’s Lives (2004) was one of the largest protests of all time in Washington, DC.  I see this example as illustrative of the ways in which the birth justice movement is more about life than about liberty and happiness.  Interestingly, life is the banner taken up by the inspiring present day grassroots movement Black Lives Matter.  Of course this second Civil Rights movement is also about liberty and happiness (in the form of dignity and respect), but who has time to espouse liberty when you and your loved ones are so busy fighting for your lives.    

An ignorant response to the Black Lives Matter movement has been “#alllivesmatter.”  If “all lives matter”ed as much as the lives of white wealthy people, particularly men, then the health care disparities in the US based on race could not possibly exist to the extent that they do.  Reforms to the US healthcare system have consistently benefited racial and ethnic minorities less than their white counterparts and this trend continues today.  US statistics on maternal and infant mortality and morbidity demonstrate that babies and women, especially black and brown babies and women, do not fare nearly as well as whites.  While the US healthcare system is in many ways failing women and infants in general when compared to other developed countries, women and babies of color are dying at alarmingly higher rates than white women and babies.  The statistics on which my above claims rest have been around since the previous century.  Despite awareness of health care disparities and social determinants of health in some sectors of the US health care non-system, meaningful changes that affect peoples’ lives on the ground have been slow to develop.  

So what do we do with this information?  Where do we go from here?  Visit our blog post titled Plugging Into this Important Work

Reference:

Oparah, J. C., & Bonaparte, A. D. (Eds.). (2015). Birthing Justice: Black Women, Pregnancy, and Childbirth. Routledge.

http://www.blackwomenbirthingjustice.org

Attempting to Measure Diversity and Inclusion

Reflections on racism and oppression in midwifery

The term “diversity” is widely used in health care literature.  The term “representative workforce” has more positive connotations than “diversity” as a condition towards which professions are striving as opposed to something white people are trying to do for or give to people of color.  The term diversity can be seen as problematic because it can connote diversity as a gift that white people and institutions aim to give to people of color.  Diversifying one’s profession, for example, allows whites to receive praise for their generosity and their role as actors in diversification.

What do you think about the term diversity?

Whether we like the term or not, it is commonly used.  Diversity, at its best, cannot be achieved or sustained without inclusion.

What do you think about the term inclusion?

Considering these terms are likely here to stay for awhile, what do you think about the idea of trying to measure diversity and inclusion?

Provided below is a list of institutions that have nurse-midwifery programs and have been granted the only national award recognizing institutions for their outstanding campus-wide diversity and inclusion efforts at the college and university level.  This recognition, titled the Higher Education Excellence in Diversity (HEED) Award, is announced annually in INSIGHT Into Diversity magazine, the largest and oldest diversity publication in higher education.  The HEED award “measures an institution’s level of achievement and intensity of commitment in regard to broadening diversity and inclusion on campus through initiatives, programs, and outreach; student recruitment, retention, and completion; and hiring practices for faculty and staff” (Insight into Diversity, 2016).  The 2016 HEED award was just recently conferred on the following institutions that have nurse-midwifery programs:

  • The Ohio State University, College of Nursing
  • Stony Brook University School of Nursing
  • SUNY Downstate Medical Center
  • University of California San Francisco
  • University of Cincinnati College of Nursing
  • University of Minnesota School of Nursing
  • University of New Mexico College of Nursing
  • University of Pennsylvania School of Nursing (Insight into Diversity, 2016).

Insight into Diversity. (2016). About the HEED award. Retrieved from http://www.insightintodiversity.com/about-the-heed-award/

Implicit Bias

Reflections on racism and oppression in midwifery

Implicit bias when unacknowledged by health care providers has the ability to manifest as contempt for the otherness they will necessarily encounter in many of their patients (Bridges, 2014).  In Reproducing Race: An Ethnography of Pregnancy as a Site of Racialization, Khiara Bridges (2014) wrote:   

When we understand that culture can be used to signify fundamental, insurmountable, difference (i.e., radical Otherness), then the cultural stereotypes and assumptions about the way people from/within certain cultures ‘just are’ may produce the same effects produced by racial discrimination. (p. 135)

Unexamined implicit bias can morph the racial stereotypes in which we have all been immersed our entire lives into cultural stereotypes which are more acceptable to utter at present.  Chapman et al. (2013) examined the phenomenon of implicit bias and found that “research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics” (p. 1504).  These authors not only provide evidence of the existence of implicit bias among physicians but they also highlight studies that demonstrate implicit bias in clinical decision-making (Chapman et al., 2013).  

Have you encountered implicit bias as a client or patient?

If you are a white midwife, what have you done to learn more about your own implicit biases?

References:

Bridges, K. (2011). Reproducing race: An ethnography of pregnancy as a site of racialization. Oakland, CA: Univ of California Press.

 

Chapman, E. N., Kaatz, A., & Carnes, M. (2013). Physicians and implicit bias: How doctors may unwittingly perpetuate health care disparities. Journal of General Internal Medicine, 28(11), 1504-1510. doi:10.1007/s11606-013-2441-1