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

LGBT Health as a Tool for Social Justice

Reflections on racism and oppression in midwifery

The article “LGBT Health as a Tool for Social Justice” stresses the importance of how health impacts and shapes society, and how a patient’s demographics affect their ability to enjoy fully healthy lives. A core principle of social justice regarding the medical field is that everyone deserves care that addresses every aspect of their lives, especially in minority populations or those on the margins where these needs are not being met. In particular, this article was discussing the disparities that LGBT people face, such as low rates of insurance coverage, anti-LGBT violence, and systemic discrimination. Due to the obstacles that LGBT people face in order to receive health care, many don’t feel safe or have access to good quality care and instead face negative health outcomes alone. This paper aims to examine the overlap between sexual orientation and gender identity that are associated with other demographics such as race and ethnicity, and how we can bridge these gaps in care. By first understanding these gaps in care and discrepancies,  we can then hope to implement change and equitable policies so everyone can receive quality care addressing every aspect of their lives. The article outlines a few intentions to intervene and how we can implement change in the medical field; by involving bystanders and allies to improve the climate in the medical setting, and dismantling the biases and stigmas that LGBT persons face.

Baker, K. (2010). LGBT Health as a Tool for Social Justice. Conference Paper: 138st APHA Annual Meeting and Exposition. Retrieved from: (Links to an external site.) Accessed November 2019.

Summary by Rachel Schmauder, 1st year Midwifery Student, Bastyr University

Doula Reimbursement: People of Color & Rural Communities

Reflections on racism and oppression in midwifery

There is a complex history between socio-demographic and historical factors surrounding women of color and rural women, and their ability to have a birth experience that is “characterized by personal agency and security, connectedness, respect, and knowledge” (Kozhimannil & Hardeman, 2015).  We have populations that would greatly benefit from doula services and don’t have access to them. Only 6% of US birthing women have doula support and many are paying anywhere from $700-1500 for private doula services (Kozhimannil & Hardeman, 2015), which is outside the financial reach of many families. Most doulas are white upper-middle class women providing support to white upper-middle class clients (Kozhimannil & Hardeman, 2015).  Doulas serving diverse racial/ethnic and class backgrounds will hopefully help reduce racial disparities in maternal and infant health (Morton & Basile, 2017). This is not feasible unless we have policies in place to advocate for doula access. Low-income women and women of color, while incredibly resilient, are groups at highest risk of poor birth outcomes and are also the most likely groups to report wanting but not having access to doula services (Kozhimannil & Hardeman, 2015).

Morton & Basile (2017) reference a study regarding a Minnesota doula program and go on to say that cost savings would only apply if the doula was reimbursed $300 or less. However, we know that this study had limitations and that many doulas charge upwards of $1000 to clients out-of-pocket. Private doulas are able to charge this amount in affluent communities because they have demonstrated their worth.  Looking further into Medicaid reimbursement for doulas, many advocates want to employ community health workers or people from the client’s specific community to be their birth doula, rather than have a doula who works for the hospital whom they don’t meet in advance (Morton & Basile, 2017).  We know from our Washington Midwife & Doula Lobby Days about the need for greater reimbursement for doulas. $300 per birth is not sustainable for a doula to make a living, and therefore creates a barrier for doulas who otherwise could represent and advocate for their own communities. In order for birthing people to feel supported, they need to trust their doula.  Again, I advocate for doulas that can be privately chosen and reimbursed rather than assigning a doula from a hospital pool.

However, for states to reimburse for doula services, do we inevitably create barriers for doulas?  Medicaid programs can only pay licensed providers in order to receive federal matching funds, so if doulas aren’t licensed, they would need to work under the supervision of a licensed clinician and bill under the clinician’s NPI number in order to be reimbursed (Kozhimannil & Hardeman, 2015).  Currently, there is no licensing body for doulas. Do we want to create some of the same issues we see in midwifery, such as increasing access to the profession by having licensure, but at the cost of creating barriers to accessing education for that profession? Do the doulas that come from communities at the highest risk for poor birth outcomes who are serving their communities even need formal doula training or is just being present as a supportive person beneficial? If doulas need to have formal training and certification or licensure to be reimbursed, will we then only approve certain programs to train doulas?  What makes a certain program approved? What if a second midwife or birth assistant provided continuous labor support? Can they then call themselves a doula and get reimbursement?

I’m very excited for the possibility of doulas getting adequate reimbursement.  I want to see doulas able to financially support themselves and serve their communities, yet at the same time I’m very concerned about the risk of creating more barriers for doulas of color or doulas from rural communities.

By Camille Friason, Bastyr University Midwifery Student



Kozhimannil, K.B. & Hardeman, R. (2015).  How Medicaid coverage for doula care could improve birth outcomes, reduce costs, and improve equity.  Retrieved from

Midwives’ Association of Washington State (MAWS). (2019). Midwife lobby day legislative agenda. Retrieved from

Morton, C.H. & Basile, M. (2017). Medicaid coverage for doula care: Re-examining the arguments through a reproductive justice lens, part one. Retrieved from

Open Arms Perinatal Services. (2019). Advocacy. Retrieved from

Active Participation in Seeking Legislative Change

Reflections on racism and oppression in midwifery

There are a variety of paths and opportunities for midwives seeking involvement in efforts to improve health equity for communities of pregnant, birthing, and postpartum persons that have been historically attacked and marginalized by the maternal healthcare system. The process of getting involved is multifaceted. Because the attack on certain communities occurs at all levels, legislative advocacy is important at all levels, be that local, regional, state, national, or global. A midwife interested in becoming involved with legislative advocacy should evaluate what level they are connected to and interested in, as there are many opportunities for legislative advocacy.

In an era of technology, online research is a frequently used method of familiarizing oneself with existing advocacy organizations. Most of them have an online platform for education and communication, such as the Black Women Birthing Justice website. Their campaign goals are clearly listed and include many calls to action that require multiple moving parts, one of them being legislative advocacy. Another resource is the website of the National Latina Institute for Reproductive Health, which describes the movement’s missions, goals, campaigns, and ways to get involved. As a midwife, reaching out to these campaigns and movements through establishing connections as a student, provider, and/or volunteer is a way to seek legislative change. In an interview with D’Almeida (2016), Alicia Bonaparte states that the birth justice movement is focused on legal and policy level action, such as forcing insurance companies to cover midwifery-led care. While there are several ways to support this legislative agenda, one strong and influential way to contribute is by working with state midwifery associations.

While some states have an active and well organized state midwifery association that works with lobbyists for legislative change, not all states have the ability to do so. One way to get involved with legislative change is to support and/or start state organizations. While states where Licensed Midwives are legal and licensed have a state professional organization, the ability and spectrum of advocacy for legislative change varies. Therefore, midwives who live in states where legislative advocacy is limited can begin constructing ways to address legislative agendas through working with their local associations. They can also work with a lobbyist or other legal professional to advance the midwifery profession by addressing issues related to oppressed and marginalized populations. On a similar note, there are currently 21 states that have a National Association of Certified Professional Midwives (NACPM) chapter, but for those working in states that do not have one, working with other midwives to begin a chapter could be influential for policy change.

Research and projects devoted to addressing health inequity for pregnant, birthing, and postpartum persons through a midwifery lens are influential for legislative advocacy as well. Bennett (2016) delves into the ways in which midwifery care for incarcerated individuals seeking prenatal, birth, and postpartum care can improve outcomes. This kind of project sheds light on a subject that can be presented to local, regional, state, and national midwifery organizations which can further bolster the building blocks of legislative agendas. Staying connected to ongoing midwifery care research allows midwives to back up legislative agendas with relevant, evidence-based information and present it to state or national midwifery associations.

The idea of seeking legislative advocacy change as a midwife in the United States can seem daunting. The U.S. community midwifery profession is not nationally recognized which poses problems and obstacles with legislative advocacy efforts. However, it is crucial for midwives to connect with their local, state, and national midwifery associations to assist in the time and effort it takes to create and execute legislative agendas and change. There are a variety of paths to go down to assist in legislative advocacy for health equity. Midwives are in a unique position to do this work, especially because there is ample evidence indicating that community midwifery provides more equitable, quality care for communities at risk. Still, it is a marginalized profession seeking wider recognition. The first step is to find out how communities that have historically been attacked by the maternal health care system have the potential to benefit from midwife-led care. From there, one can directly support relevant campaigns by volunteering or establishing connections between existing campaigns and their state midwifery association. Furthermore, a powerful use of time and effort is assisting in the development of state-level midwifery associations in order to formulate and act on legislative agendas.

Written by Emily Jones, Bastyr University Midwifery Student



Bennett, R. B. (2016). Locked Out of Options: Advocacy & Utilization of the Midwifery Model of Care for Pregnant Prisoners in the United States (Unpublished master’s capstone). Bastyr University: Kenmore, WA.

D’Almeida, K. (2016). Exploring birth justice: A conversation with Julia Chinyere Oparah and Alicia Bonaparte. Retrieved from

Morton, C.H. & Basile, M. (2017). Medicaid coverage for doula care: Re-examining the arguments through a reproductive justice lens, part one. Retrieved from

National Latina Institute For Reproductive Health. (n.d.). Retrieved from

Oparah, C., Jones, L., Hudson, D., Oseguera, T., & Arega, H. (2017). Battling over birth: Black women & the maternal health care crisis in California. Retrieved from

Culturally Sensitive Care Aims to Improve Indigenous Maternal and Child Health

Reflections on racism and oppression in midwifery

In a CBC news report ‘We can’t do it alone,’ Julia Whalen informs readers about a recent $2.6 million grant that researchers in Toronto have received. This grant will be used to fund the “Kind Faces Sharing Places: An Action Research Project for Indigenous Families During and After Pregnancy and Birth,” a team-based program aimed at providing better quality healthcare to First Nations populations (Whalen, 2017).

This big win is supported by several partners who hope to reduce infant mortality rates, which are up to four times the national average in First Nation populations, among other things (Whalen, 2017). This unique program is “Indigenous-led, it has community and women’s voices at the heart of it, it is a multidisciplinary, multi-sectoral approach to deal with all the upstream drivers that eventually lead to poor maternal and infant health outcomes,” and will provide better accessibility to culturally secure and safe care (Whalen, 2017). Many different factors affecting accessibility to quality care include lack of housing, access to transportation, and mental health issues. This is why the program aims to create a “spiderweb of support” with partners like the University of Toronto’s Waakebiness-Bryce Institute for Indigenous Health, Nishnawbe Homes, and Seventh Generation Midwives Toronto (Whalen, 2017).

The program plans to recruit 100 mothers and their families to take part in a three-year study where they will receive care from a team led by Indigenous midwife, Sara Wolfe (Whalen, 2017). Participants will be connected with mental health care providers, social service agencies, housing transition support, as well as traditional counseling and healing. Treatment for addictions will also be offered. The importance of this program is to provide culturally appropriate care for Indigenous people facing a variety of different issues, at different levels within the community (Whalen, 2017). The program will evaluate the results each year.

Written by Andy Carmichael, Bastyr University Midwifery Student



Whalen, J. (2017, May 25). We can’t do it alone: Indigenous maternal health program aims to address inequality of health care. Retrieved from

Review of Black Mamas Matter: A Toolkit for Advancing the Human Right to Safe and Respectful Maternal Health Care

Reflections on racism and oppression in midwifery


First, let me start off by saying how amazing and informal I found this article to be!! As you read through the article, it hits every aspect and problem regarding the US and global birth outcomes among African American women. The article starts off by talking about the Black Mamas Matter Toolkit that was first published in 2016 by the Center for Reproductive Rights. The toolkit began as a group of people meeting to ask tough questions about the state of Black maternal health and has grown to a national movement of stakeholders committed to changing the world so that Black mamas have the rights, respect, and resources they need to have safe and healthy pregnancy outcomes.

The Black Mamas Matter Alliance (BMMA) is a Black women-led, cross-sectoral alliance. Their center focus is to get Black mamas to advocate, drive research, build power, and shift culture for Black maternal health, rights, and justice. Their toolkit has helped lay the groundwork for policy change while highlighting Black mamas’ human rights to safe and respectful care. It provides a comprehensive overview of information and resources on Black maternal health and identifies actions policymakers can take to address maternal health within the human rights and reproductive justice frameworks. Similar to the article, I also believe that every woman has the right to a safe pregnancy, childbirth, and respectful maternal care. The article states how these things are rooted in the human rights standards of life, health, equality, and non-discrimination. Governments must ensure these rights by creating enabling conditions that support healthy women, healthy pregnancies, and healthy births.

The article also highlights a study that was conducted in 2000 that notes a historic agreement made by the international community to work together to improve maternal health. Improving maternal health and survival became a shared, global priority and one of the eight Millennium Development Goals (MDGs) that all countries agreed to pursue. Since 1990, the MDGs have guided the international development agenda, which has contributed to a nearly 50% reduction in the global maternal mortality ratio (MMR) between 1990 and 2015. Unfortunately, the United States failed to reduce its’ own MMR during this time frame

The major issue the article touches on is how the overall proportion of women who do not survive pregnancy and childbearing is on the rise in this country and marginalized women tend to be at greater risk than others. To be specific, Black women are dying at a rate three to four times higher than White women, a pattern that has persisted across the US for generations. In some American cities, the MMR for Black women is now higher than the MMR in many developing countries, which is beyond my understanding. The article holds to the standard that all women need the resources, opportunities, and support that enable them to protect their human rights to health and life and to make the best decisions for themselves and their families.

Written by Nikita Thomas, Bastyr University Midwifery Student


References (article and image):

Black Mamas Matter: A Toolkit for Advancing the Human Right to Safe and Respectful Maternal Health Care. (2013, January 03). Retrieved from

Intersex Awareness

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


how many
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!



Learn More Here! Resources for Intersex Education
InterACT Advocates for Intersex Youth
Intersex Justice Project
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

Association of Ontario Midwives. (2018). AOM position statement on intersex child autonomy. Retrieved from

Intersex Society of North America. (n.d.) What’s wrong with the way intersex has traditionally been treated? Retrieved from

United Nations Free & Equal. (2018). United nations for intersex awareness. Retrieved from

4Intersex. (2018). Intersex 101: Everything you need to know. Retrieved from

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.


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

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.


Alvarez, L. & Goodnough, A. (2015). Puerto Ricans Brace for Crisis in Health Care. Accessed online at

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

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:
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.